NSE31 - Week 4 Exam
Study Guide
What are the three phases of transition for the newborn when the umbilical cord is cut? -
ANSWER Phase one: "Period of reactivity" - 1-2 hrs
Phase two: "Sleep period" - 1-4 hrs post birth
Phase three: "Second period of reactivity" - 2-8 hrs following phase 2
When does the nurse have to perform assessments to the newborn? - ANSWER
Immediately after birth
1 hr after birth; 2 hrs after birth
q6h during inpatient stay; before discharge
When do you do apgar scoring? - ANSWER Done at 1 and 5 minutes post birth
- then 10 minutes later if initial distress or delayed transition to extrauterine life
What are the 5 key areas of APGAR scoring? - ANSWER 1. Appearance (skin colour)
2. Pulse
3. Grimace response (reflex irritability)
4. Activity and muscle tone
5. Respiration (breathing effort and rate)
0-3 = severely depressed
4-6 = moderately depressed
7-10 = excellent condition
What are the newborn adaptations in the respiratory system? - ANSWER Alveoli inflate
with help of surfactant
Lungs clear of fluid
What are the newborn adaptations in the cardiovascular system? - ANSWER Decreased
pulmonary vascular resistance
What are the newborn adaptations in the neurological system? - ANSWER Reflexes aid
in transition to extrauterine life
, What are the newborn adaptations in the hematological system? - ANSWER Fetal Hb -
high affinity for oxygen to promote oxygenation while infant begins producing own Hb
postnatally
What are the newborn adaptations in the GI/Hepatic system? - ANSWER Conjugation of
bilirubin begins
Peristalsis begins, digestive enzymes excreted
Glycogen synthesized in liver and muscles
What are the newborn adaptations in the urinary system? - ANSWER Newborn does not
yet have good ability to dilute or concentrate urine
What are the newborn adaptations in the immune system? - ANSWER Protected by
maternal antibodies for 4-6 months
Breastfed infants receive antibodies from breastmilk (IgE, IgM, Ig G)
Healthy infants begin producing own antibodies at 2-3 months of age
What are the elimination patters for the 1st week? - ANSWER Day 1 - 1 diaper/day -
Thick, tarry, black stool (meconium)
Day 2 - 2 diapers/day - thick, tarry, black
Day 3 - 3 diapers/day - greenish/yellow
Day 4 - 5-6 diapers/day - transition to seedy, watery, mustard yellow
What is the order of the head to toe assessment for newborns? - ANSWER Newborns are
sensitive to touch
Assess from least to most invasive
Observe 1st, auscultate without disturbing the infant; palpate after everything else is
done
How do you get vitals from infant? - ANSWER Heart
Obtain apical pulse while infant at rest. Use infant stethoscope if possible
Point of maximal impulse - left mid-clavicular line at 5th intercostal space
What are normal findings for newborn's vital signs? - ANSWER Normal resting rate -
110-160 bpm (can fluctuate: 100 during sleeping; 180 when crying)
May hear murmurs during 1st few hrs. - as foramen ovale is closing
How do you assess newborn's respirations and temperature? - ANSWER Respirations
- observe rise/fall of chest for 1 minute
Study Guide
What are the three phases of transition for the newborn when the umbilical cord is cut? -
ANSWER Phase one: "Period of reactivity" - 1-2 hrs
Phase two: "Sleep period" - 1-4 hrs post birth
Phase three: "Second period of reactivity" - 2-8 hrs following phase 2
When does the nurse have to perform assessments to the newborn? - ANSWER
Immediately after birth
1 hr after birth; 2 hrs after birth
q6h during inpatient stay; before discharge
When do you do apgar scoring? - ANSWER Done at 1 and 5 minutes post birth
- then 10 minutes later if initial distress or delayed transition to extrauterine life
What are the 5 key areas of APGAR scoring? - ANSWER 1. Appearance (skin colour)
2. Pulse
3. Grimace response (reflex irritability)
4. Activity and muscle tone
5. Respiration (breathing effort and rate)
0-3 = severely depressed
4-6 = moderately depressed
7-10 = excellent condition
What are the newborn adaptations in the respiratory system? - ANSWER Alveoli inflate
with help of surfactant
Lungs clear of fluid
What are the newborn adaptations in the cardiovascular system? - ANSWER Decreased
pulmonary vascular resistance
What are the newborn adaptations in the neurological system? - ANSWER Reflexes aid
in transition to extrauterine life
, What are the newborn adaptations in the hematological system? - ANSWER Fetal Hb -
high affinity for oxygen to promote oxygenation while infant begins producing own Hb
postnatally
What are the newborn adaptations in the GI/Hepatic system? - ANSWER Conjugation of
bilirubin begins
Peristalsis begins, digestive enzymes excreted
Glycogen synthesized in liver and muscles
What are the newborn adaptations in the urinary system? - ANSWER Newborn does not
yet have good ability to dilute or concentrate urine
What are the newborn adaptations in the immune system? - ANSWER Protected by
maternal antibodies for 4-6 months
Breastfed infants receive antibodies from breastmilk (IgE, IgM, Ig G)
Healthy infants begin producing own antibodies at 2-3 months of age
What are the elimination patters for the 1st week? - ANSWER Day 1 - 1 diaper/day -
Thick, tarry, black stool (meconium)
Day 2 - 2 diapers/day - thick, tarry, black
Day 3 - 3 diapers/day - greenish/yellow
Day 4 - 5-6 diapers/day - transition to seedy, watery, mustard yellow
What is the order of the head to toe assessment for newborns? - ANSWER Newborns are
sensitive to touch
Assess from least to most invasive
Observe 1st, auscultate without disturbing the infant; palpate after everything else is
done
How do you get vitals from infant? - ANSWER Heart
Obtain apical pulse while infant at rest. Use infant stethoscope if possible
Point of maximal impulse - left mid-clavicular line at 5th intercostal space
What are normal findings for newborn's vital signs? - ANSWER Normal resting rate -
110-160 bpm (can fluctuate: 100 during sleeping; 180 when crying)
May hear murmurs during 1st few hrs. - as foramen ovale is closing
How do you assess newborn's respirations and temperature? - ANSWER Respirations
- observe rise/fall of chest for 1 minute
