N352 Exam 4 Questions and Correct Answers
HRN concepts
-confort
-family
-fluid and electrolyte
-grief and loss
-infection
-thermoregulation
-oxygenation
-tissue integroty
-safety
-stress and coping
-growth and development
preterm: classification based on gestational age
-before 37 weeks
-less than 28 weeks = extremely premature
-28-31 6/7 = very prematire
-32-33 6/7 = premature
-34 - 36 6/7 = late premature
preterm: classification based on weight
-extremely low brith weight= less than 1,000 grams
-very low birth weight= 1,000-1,499 grams
-low birth weight = 1,500 - 2,500 gram
,gestational age and assessment finding:
-tone/flexion
-skin
-subcutaneous fat
-lanugau
-foot creases
-eyelids
-genitals
complication of pregnancy
-Oxygenation: surfactant deficiency, inability to exchange gas
-Perfusion: PDA, hypovolemia, ductus closure
-Fluid/electrolyte: trans epidermal water loss (TEWL), immature kidney unable to
concentrate
-Infection: immature immune system, immature liver, thin skin
-thermoregulation: thin skin, no subcutaneous fat, no muscel tone, no brown fat, no reserve
-nutrition: no suck/swallow breath until 34 weeks, no reserve to maintain glucose
-growth and development: sparse myelenization of nerve endings easily stressed
premature nursing intervention: maintain patent airway
-intubation, surfactant, oxygen therapy
premature nurisng interventions: maintain perfusion
-monitor BP/arterial pressures, intraventricular hemorrhage, monitor H and H
premature nursing interventions: maintain fluid and electrolyte
-monitor I and O (weight diapers), monitor s/s of pulmonary edema, monitor labs
,premature nursing interventions: nutrition
-encourage mom to pump, swab oral airway with EBM, daily weight
premature nursing interventions: infection
-hand washing, monitor for s/s of infection, monitor for NEC, pneumonia
premature nursing interventions: developmental cares
-calm environment, lights dim, cluster
RDS
underdeveloped and insufficent levels of surfactant cause ATELECTASIS
-hypoxemia and hypercarbia
-pulmonary artery vasoconstriction
-right to left shunting through ductus arteriosus and foramen ovale
-metabolic and respiratory acidosis (build up of lactic acid and carbon dioxide)
RDS: complications
PDA, pneumothroax, ROP, hypotension, IVH
RDS: assessment
tachycardia
expiraotry grunting
-nasal flaring
-gray in color
-retractions
RDS management: medical
, -surfactant
-ventilation
-ET tube, CPAP, oscillatory vent
-antibiotics
RDS management: nurse
-maintain airway
-movitor VS, lab, x-ray, I and O
-maintain body temp
bronchopulmonary dysplasia
-decreased lung complicance due to mechanical ventilation beyond 28 days
-increased pulmonary vascular resistance
BPD : complications
-intermittent bronchospasm
-difficulty weaning from oxygen
-recurrent infection
-CHF
BPD: assessments
retraction, wheezes, rales, rhonchi, intolerance to fluids
BPD management: medical
-monitor
-bronchodialtor
-corticosteorids
HRN concepts
-confort
-family
-fluid and electrolyte
-grief and loss
-infection
-thermoregulation
-oxygenation
-tissue integroty
-safety
-stress and coping
-growth and development
preterm: classification based on gestational age
-before 37 weeks
-less than 28 weeks = extremely premature
-28-31 6/7 = very prematire
-32-33 6/7 = premature
-34 - 36 6/7 = late premature
preterm: classification based on weight
-extremely low brith weight= less than 1,000 grams
-very low birth weight= 1,000-1,499 grams
-low birth weight = 1,500 - 2,500 gram
,gestational age and assessment finding:
-tone/flexion
-skin
-subcutaneous fat
-lanugau
-foot creases
-eyelids
-genitals
complication of pregnancy
-Oxygenation: surfactant deficiency, inability to exchange gas
-Perfusion: PDA, hypovolemia, ductus closure
-Fluid/electrolyte: trans epidermal water loss (TEWL), immature kidney unable to
concentrate
-Infection: immature immune system, immature liver, thin skin
-thermoregulation: thin skin, no subcutaneous fat, no muscel tone, no brown fat, no reserve
-nutrition: no suck/swallow breath until 34 weeks, no reserve to maintain glucose
-growth and development: sparse myelenization of nerve endings easily stressed
premature nursing intervention: maintain patent airway
-intubation, surfactant, oxygen therapy
premature nurisng interventions: maintain perfusion
-monitor BP/arterial pressures, intraventricular hemorrhage, monitor H and H
premature nursing interventions: maintain fluid and electrolyte
-monitor I and O (weight diapers), monitor s/s of pulmonary edema, monitor labs
,premature nursing interventions: nutrition
-encourage mom to pump, swab oral airway with EBM, daily weight
premature nursing interventions: infection
-hand washing, monitor for s/s of infection, monitor for NEC, pneumonia
premature nursing interventions: developmental cares
-calm environment, lights dim, cluster
RDS
underdeveloped and insufficent levels of surfactant cause ATELECTASIS
-hypoxemia and hypercarbia
-pulmonary artery vasoconstriction
-right to left shunting through ductus arteriosus and foramen ovale
-metabolic and respiratory acidosis (build up of lactic acid and carbon dioxide)
RDS: complications
PDA, pneumothroax, ROP, hypotension, IVH
RDS: assessment
tachycardia
expiraotry grunting
-nasal flaring
-gray in color
-retractions
RDS management: medical
, -surfactant
-ventilation
-ET tube, CPAP, oscillatory vent
-antibiotics
RDS management: nurse
-maintain airway
-movitor VS, lab, x-ray, I and O
-maintain body temp
bronchopulmonary dysplasia
-decreased lung complicance due to mechanical ventilation beyond 28 days
-increased pulmonary vascular resistance
BPD : complications
-intermittent bronchospasm
-difficulty weaning from oxygen
-recurrent infection
-CHF
BPD: assessments
retraction, wheezes, rales, rhonchi, intolerance to fluids
BPD management: medical
-monitor
-bronchodialtor
-corticosteorids
