NUR 1510 Unit 2 Review Questions and Correct Answers
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Course
NUR 1510
Institution
NUR 1510
Assessment: Source of Data Collection •Maternal and fetal history -Prenatal -Labor and Delivery •Physical Exam/Observations -Initial -Ongoing •Anthropometric measurements •Vital signs •Skin - Condition, color, lesions •Head: fontanels
Growth (LGA, AGA, SGA) Large for gestational age (L...
NUR 1510 Unit 2 Review Questions and
Correct Answers
Assessment: Source of Data Collection ✅•Maternal and fetal history
-Prenatal
-Labor and Delivery
•Physical Exam/Observations
-Initial
-Ongoing
•Anthropometric measurements
•Vital signs
•Skin - Condition, color, lesions
•Head: fontanels
Growth (LGA, AGA, SGA) ✅Large for gestational age (LGA) greater than 90%
Appropriate for gestational age (AGA) 10%-90%
Small for gestational age (SGA) less than 10%
Normal Newborn Vital Signs ✅•Pulse= 110-160
-Always taken apically for one minute
-Assess peripheral pulses bilaterally for symmetry not rate
•Respirations= 30-60
-Pauses in breathing for 5 to 10 seconds are normal
-Irregular rate
•Temperature= 36.5-37.5
-Taken axillary
•Pain Score
-NIPS
-FLACC
Vital signs are checked every 30" for the first two hours of life, then at 4 hours, followed
by q 8 hours
Newborn Care in the Delivery Room ✅•Airway patency
•Dry Infant
•Maintaining thermoregulation
-Skin to skin
-Under the warmer
•Suction Mouth & Nose with Bulb Syringe
•Prescribed medications
-Vitamin K
-Eye prophylaxis
Development of Lungs ✅•Fetal lung fluid
, •Surfactant is produced as lungs mature
-Reduces surface tension within alveoli
-Surfactant usually sufficient by 34 to 36 weeks of gestation
Initiation of Respirations ✅First breath must force fluid into interstitial spaces -
Requires negative pressure
Internal:
Chemical
Decreased PO2, increased CO2, decreased pH
Surfactant
¯ surface tension in alveoli
External:
Mechanical (squeezing of chest)
Thermal (lower temperature)
Sensory (noise, lights)
Tactile stimulation
Normal Respiratory Patterns ✅•30 - 60 bpm
•Irregular Pattern
•Pauses in breathing for 5 to 10 seconds
•Shallow breaths
•Nose breathers
•No audible sounds
•Abdominal breathers
•Symmetrical chest wall movement
5 Symptoms of Respiratory Distress ✅-Flaring of Nares
-Tachypnea (rate greater 60 bpm)
-Expiratory Grunting
-Retractions: Sub-sternal, Intercostal
-Dusky Color, Circumoral Cyanosis
*Signs do not have to occur in this order
Symptoms of Hypothermia ✅•Cry
•Restless
•Increased flexion
•Acrocyanosis
Non-Shivering Thermogenesis ✅•Create heat without shivering
•Metabolize brown fat to create heat (unique to an infant)
•Metabolism uses more oxygen and more glucose
-Metabolic rate can increase 200-300%
-Assess for respiratory distress
-Assess for hypoglycemia
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