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Multiple Choice
A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take to obtain an accurate measurement?
A
Estimate the heart rate by observing the chest movements.
B
Measure the radial pulse for 30 seconds and double the result.
C
Count the heartbeats for 15 seconds and multiply by 4.
D
Use a stethoscope to listen to the apical pulse for a full minute.
Verified step by step guidance
1
Understand the importance of accuracy in measuring a newborn's heart rate, as it is crucial for assessing the baby's health status.
Recognize that the apical pulse, located at the apex of the heart, provides the most accurate heart rate measurement in newborns.
Use a stethoscope to listen directly to the apical pulse, which is typically found at the left side of the chest, just below the nipple line.
Count the heartbeats for a full 60 seconds to ensure an accurate measurement, as newborns can have irregular heart rhythms that might be missed with shorter counting intervals.
Avoid using methods like observing chest movements or measuring the radial pulse, as these can be less reliable in newborns due to their small size and rapid heart rates.