A newborn is crying lustily when the nurse assesses vital signs. His apical heart rate is 170 . The nurse should
a. notify the pediatrician and prepare an IV setup
b. record the findings and continue with the assessment
c. record the findings and recheck the rate when the infant has quieted
d. request another nurse to take the apical pulse to verify your finding
C
The findings should be recorded, with a notation that the neonate was crying and then rechecked after the neonate has quieted. It is not necessary to notify the pediatrician and prepare an IV setup because an increased heart rate accompanies crying in the neonate normally.
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