NU 328 TEST 2 GUIDE WITH
COMPLETE SOLUTION
Bone to bone - ANSWER ligaments
muscle to bone - ANSWER tendons
growth plate on bone ends - ANSWER epiphyses
swayback - ANSWER lordosis
humpback - ANSWER kyphosis
S curvature of the vertebra - ANSWER scoliosis
RIPS - ANSWER R= range of motion
I= inspection
P= palpation
S= strength
crunching as felt on the knee when moving it; can be felt on all joints -
ANSWER crepitation
pulses - ANSWER carotid, brachial, radial, femoral, popliteal, dorsal pedis,
posterior tibial
Five Ps for Neurovascular Assessment - ANSWER pain, pulses, pallor,
paresthesia, paralysis
should not be out of proportion than you expect; this on passive stretch
,means they have to much swelling or compression; this out of proportion to
you what you expected, is a red flag - ANSWER pain
checking for paleness that can cause problems; check everything for
discoloration - ANSWER pallor
tingling and numbness; most likely pressure on a nerve; numbness is not
circulation, its pressure on the nerve - ANSWER parasthesia
when nothing can move; means trouble - ANSWER paralysis
A newborn is between the ages of _______ - _________ days. - ANSWER 0 and 28
assesses early cardiopulmonary adaptation; how the heart and lungs adapt to
outside uterine life - ANSWER apgar score
how many weeks mature the baby is when it is born; by dates vs. by exam -
ANSWER gestational age assessment
classified by gestational age and weight; SGA, AGA, LGA - ANSWER
classification of a newborn
nurses do this when the baby is one minute and again at 5 minutes old; each
category is given a rating (0-2); the best apgar score is 10; most babies get a
9 because of acrocyanosis; the score is not a predictor; 8,9,10 indicates a
satisfactory score and no intervention; <4 = resuscitation may be needed;
measure HR, RR, muscle tone, reflex irritability, and skin color - ANSWER
apgar score
When is the apgar score determined? - ANSWER at one and 5 minutes
the best apgar score is a _______. - ANSWER 10
blueness of extremities that is typical in a newborn which causes them not to
,get a 2 in the skin color category - ANSWER acrocyanosis
What apgar score indicates a satisfactory score and no intervention? -
ANSWER 8,9,10
What apgar score indicates intervention? - ANSWER 5,6,7
What apgar indicates resuscitation may be needed? - ANSWER < 4
What all is measured in the apgar score? - ANSWER HR, RR, muscle tone,
reflex irritability, and skin color
measures the maturity or gestational age of an infant; assesses 6 physical
and 6 neuromuscular signs and gives each a score; the cumulative score
correlates with the gestational age of the infant; can be done on infant 20-44
weeks gestation - ANSWER ballard scale
What age is the ballard scale done on? - ANSWER 20-44 weeks gestation
How often is the ballard scale performed? - ANSWER when they are born and
at 12 hours
neuromuscular areas examined on the ballard scale: - ANSWER posture,
square window, arm recoil, popliteal angle, scarf sign, heel to ear
physical maturity areas examined on the ballard scale: - ANSWER skin,
lanugo, plantar surface, breast, eye/ear, and genitals of males and females
T/F: Classification of newborn by both weight and gestational age is the best
predictor of risk. - ANSWER True
appropriate weight for gestational age: - ANSWER AGA
large weight for gestational age: - ANSWER LGA
, small weight for gestational age: - ANSWER SGA
< 37 weeks - ANSWER premature
> 42 weeks - ANSWER post mature
Term infant weighs: - ANSWER 2500g to 4000g
Temperature range of a newborn: - ANSWER 97.7-100 degrees F axillary
Temperature should be assessed frequently until stable for _____ hours after
birth. - ANSWER 2
HR in newborns: - ANSWER 120-160 when awake and quiet
How long should you count the apical rate for? - ANSWER 1 minute
RR in newborns: - ANSWER 30-60/min
BP in newborns: - ANSWER 60-80/40-50; check in UE and LE
Pulse oximetry in newborns: - ANSWER > 95 %
done after birth; baby should be smooth and can possibly be swollen
depending on their delivery; may have acrocyanosis; should be moving all
extremities and should be symmetrical; look for rashes, lesions, birth marks,
and describe them just as you would on an adult - ANSWER inspection
the same procedure used on adults; looking for masses or lumps - ANSWER
palpation
checked on abdomen; should have quick recoil; if the skin stays, that is a sign
of dehydration - ANSWER skin turgor
normal cheesy like substance that baby has in utero which is thought to keep
him warm - ANSWER vernix