NSPN 7100 TEST EVALUATION QUESTIONS AND
ANSWERS SET A+
✔✔DSC - ✔✔-is based on the fact that infant behavioral cues communicate the infant's
needs, feelings, and overall neurologic status
-is based on the fact that infants continually interact with their environment
-involves altering the neonatal environment to nurture each of the infants' sensory
processes (tactile/kinesthetic, auditory, visual, and olfactory/gustatory)
-guides our decision making when providing care to infants
-creates an environment that nurtures brain growth and minimizes brain injury for
optimal overall development
✔✔What does habituation mean? - ✔✔Habituation means the infant is able to tune out
and decrease their response to a stimuli.
✔✔What is the primary method used for communication by infants? - ✔✔Infants
primarily use behaviours to communicate with their parents/care providers.
✔✔Marnie wants to know if her baby can see her. What can you tell her? - ✔✔Infants
can see objects as far away as 2 feet, but clearest visual distance is 8-12 inches. They
prefer faces and can recognize their mother's face.
✔✔What are four stress cues a newborn may exhibit? - ✔✔Hiccoughing, finger
splaying, arching/stiffening, apnea, frowning, sneezing, gaze aversion, irritable,
sneezing.
✔✔What are 4 interventions or care practices that support developmentally supportive
care? - ✔✔Skin to skin care, encouraging parents to talk to their infant, decreasing
,noise when feeding infant, reading infant behavioural cues, swaddling infant, gentle
touch to calm infants.
✔✔Goals of care for infants include - ✔✔Pink, Warm, Sweet, Organized, Attached,
Clean (PWSOAC) framework
✔✔Pink - ✔✔-at birth, the lungs must take on the role of gas exchange. Neonates are
primarily nasal breathers and the normal respiratory rate of the newborn is 30-60
breaths per minute. Respirations are initially shallow and irregular with occasional
pauses lasting less than 20 seconds
-Some newborns still have mucus to clear from their respiratory tract and may require
suctioning in the first 24 hours after birth.
-Assessing an infant's respiratory rate, color, tone, and heart rate are important ongoing
assessments related to oxygenation. Color should be pink, tone should be flexed, and
the normal heart rate for a newborn is 100-160 bpm.
✔✔The three cardinal signs of respiratory distress in the newborn are: - ✔✔nasal
flaring, indrawing or retractions, and grunting.
✔✔Warm - ✔✔Heat regulation is critical to the neonate's survival. The normal
temperature for a newborn should be between 36.5 and 37.4 degrees Celsius axilla.
Newborns are vulnerable to heat loss and during the first 48 hours, the newborn is still
trying to achieve thermal balance or thermoregulation.
✔✔Newborns have specific characteristics which make them vulnerable to heat loss
including: - ✔✔-Thin layer of subcutaneous fat
-Blood vessels are close to the surface of the skin
-Changes in environmental temperature alter blood temperature which impact
temperature regulation centers in the hypothalamus
-Larger surface-to-body weight ratios
✔✔Sweet - ✔✔At birth when the umbilical cord is cut, the newborn no longer receives
the maternal source of glucose. Therefore, in order to maintain a normal blood sugar,
infant feeding should be established in the first few hours of life.
✔✔Clinical signs of hypoglycemia in the newborn include - ✔✔glucose of 2.6
tremors, jitteriness, irritability, lethargy, pallor, temperature instability and breathing
difficulties.
✔✔What are the normal heart rate, respiratory rate and temperature for a newborn? -
✔✔Normal heart rate is 100-160 bpm, normal respiratory rate is 30-60 breaths per
minute and normal temperature is 36.5-37.4 degrees Celsius.
, ✔✔What does thermoregulation mean? - ✔✔Thermoregulation is the maintenance of
balance between heat loss and heat production.
✔✔Name two factors that contribute to an infant's vulnerability to heat loss. - ✔✔Infants
are vulnerable to heat loss because they have a thin layer of subcutaneous fat, their
blood vessels are close to the surface of the skin, changes in environmental
temperature alter blood temperature which impact temperature regulation centers in the
hypothalamus, and they have a larger surface-to-body weight ratio.
✔✔How would a nurse prevent heat loss in an infant? - ✔✔Immediate drying at time of
delivery, keeping the infant skin to skin with the mother, placing a hat on the infant's
head, keeping the infant off of cool surfaces and away from drafts, ensuring the infant is
bundled when not skin to skin with a parent.
✔✔Marnie wants to know how she will know her baby is hungry. - ✔✔The infant may
bring her hand or fist to her mouth, she may turn her head towards the breast or if her
cheek is stroked, and she may make sucking motions with mouth or tongue.
✔✔Is there anything in Marnie's pregnancy, labour or birth story that would increase the
risk of hypoglycemia in her newborn? - ✔✔No, Marnie had a healthy pregnancy, no risk
factors, and a normal labour and birth. Her infant is term, normal weight, and was
placed skin to skin at delivery.
✔✔Organized - ✔✔-Stable heart rate, color
-Tolerance of feeding
-Smooth and synchronous movements
-Smooth transitions between sleep and wake cycles
-Uses self-consoling behaviours
-Ability to shut out (Habituation) noxious or repetitive stimuli
✔✔Disorganized - ✔✔-Fluctuations in heart rate and respiratory rate. May experience
bradycardias and/or apnea
-Inability to tolerate feeds, increased stooling
-Hiccups, sneezing, gagging, yawning
-Frantic body movements and jitteriness, changes in muscle tone
-Inability to modulate state, sudden changes from sleep to wake
-Limited use of self-consoling behaviours
-Inability to be consoled
-Inability to habituate
✔✔What assessments data would indicate to you that Marnie and Ted's infant is
organized? - ✔✔Marnie and Ted's infant is a healthy term infant which is the first
assessment that supports organization. I would assess physiologic function by
assessing vital signs. If the infant is organized I would observe, stable vital sign, good
ANSWERS SET A+
✔✔DSC - ✔✔-is based on the fact that infant behavioral cues communicate the infant's
needs, feelings, and overall neurologic status
-is based on the fact that infants continually interact with their environment
-involves altering the neonatal environment to nurture each of the infants' sensory
processes (tactile/kinesthetic, auditory, visual, and olfactory/gustatory)
-guides our decision making when providing care to infants
-creates an environment that nurtures brain growth and minimizes brain injury for
optimal overall development
✔✔What does habituation mean? - ✔✔Habituation means the infant is able to tune out
and decrease their response to a stimuli.
✔✔What is the primary method used for communication by infants? - ✔✔Infants
primarily use behaviours to communicate with their parents/care providers.
✔✔Marnie wants to know if her baby can see her. What can you tell her? - ✔✔Infants
can see objects as far away as 2 feet, but clearest visual distance is 8-12 inches. They
prefer faces and can recognize their mother's face.
✔✔What are four stress cues a newborn may exhibit? - ✔✔Hiccoughing, finger
splaying, arching/stiffening, apnea, frowning, sneezing, gaze aversion, irritable,
sneezing.
✔✔What are 4 interventions or care practices that support developmentally supportive
care? - ✔✔Skin to skin care, encouraging parents to talk to their infant, decreasing
,noise when feeding infant, reading infant behavioural cues, swaddling infant, gentle
touch to calm infants.
✔✔Goals of care for infants include - ✔✔Pink, Warm, Sweet, Organized, Attached,
Clean (PWSOAC) framework
✔✔Pink - ✔✔-at birth, the lungs must take on the role of gas exchange. Neonates are
primarily nasal breathers and the normal respiratory rate of the newborn is 30-60
breaths per minute. Respirations are initially shallow and irregular with occasional
pauses lasting less than 20 seconds
-Some newborns still have mucus to clear from their respiratory tract and may require
suctioning in the first 24 hours after birth.
-Assessing an infant's respiratory rate, color, tone, and heart rate are important ongoing
assessments related to oxygenation. Color should be pink, tone should be flexed, and
the normal heart rate for a newborn is 100-160 bpm.
✔✔The three cardinal signs of respiratory distress in the newborn are: - ✔✔nasal
flaring, indrawing or retractions, and grunting.
✔✔Warm - ✔✔Heat regulation is critical to the neonate's survival. The normal
temperature for a newborn should be between 36.5 and 37.4 degrees Celsius axilla.
Newborns are vulnerable to heat loss and during the first 48 hours, the newborn is still
trying to achieve thermal balance or thermoregulation.
✔✔Newborns have specific characteristics which make them vulnerable to heat loss
including: - ✔✔-Thin layer of subcutaneous fat
-Blood vessels are close to the surface of the skin
-Changes in environmental temperature alter blood temperature which impact
temperature regulation centers in the hypothalamus
-Larger surface-to-body weight ratios
✔✔Sweet - ✔✔At birth when the umbilical cord is cut, the newborn no longer receives
the maternal source of glucose. Therefore, in order to maintain a normal blood sugar,
infant feeding should be established in the first few hours of life.
✔✔Clinical signs of hypoglycemia in the newborn include - ✔✔glucose of 2.6
tremors, jitteriness, irritability, lethargy, pallor, temperature instability and breathing
difficulties.
✔✔What are the normal heart rate, respiratory rate and temperature for a newborn? -
✔✔Normal heart rate is 100-160 bpm, normal respiratory rate is 30-60 breaths per
minute and normal temperature is 36.5-37.4 degrees Celsius.
, ✔✔What does thermoregulation mean? - ✔✔Thermoregulation is the maintenance of
balance between heat loss and heat production.
✔✔Name two factors that contribute to an infant's vulnerability to heat loss. - ✔✔Infants
are vulnerable to heat loss because they have a thin layer of subcutaneous fat, their
blood vessels are close to the surface of the skin, changes in environmental
temperature alter blood temperature which impact temperature regulation centers in the
hypothalamus, and they have a larger surface-to-body weight ratio.
✔✔How would a nurse prevent heat loss in an infant? - ✔✔Immediate drying at time of
delivery, keeping the infant skin to skin with the mother, placing a hat on the infant's
head, keeping the infant off of cool surfaces and away from drafts, ensuring the infant is
bundled when not skin to skin with a parent.
✔✔Marnie wants to know how she will know her baby is hungry. - ✔✔The infant may
bring her hand or fist to her mouth, she may turn her head towards the breast or if her
cheek is stroked, and she may make sucking motions with mouth or tongue.
✔✔Is there anything in Marnie's pregnancy, labour or birth story that would increase the
risk of hypoglycemia in her newborn? - ✔✔No, Marnie had a healthy pregnancy, no risk
factors, and a normal labour and birth. Her infant is term, normal weight, and was
placed skin to skin at delivery.
✔✔Organized - ✔✔-Stable heart rate, color
-Tolerance of feeding
-Smooth and synchronous movements
-Smooth transitions between sleep and wake cycles
-Uses self-consoling behaviours
-Ability to shut out (Habituation) noxious or repetitive stimuli
✔✔Disorganized - ✔✔-Fluctuations in heart rate and respiratory rate. May experience
bradycardias and/or apnea
-Inability to tolerate feeds, increased stooling
-Hiccups, sneezing, gagging, yawning
-Frantic body movements and jitteriness, changes in muscle tone
-Inability to modulate state, sudden changes from sleep to wake
-Limited use of self-consoling behaviours
-Inability to be consoled
-Inability to habituate
✔✔What assessments data would indicate to you that Marnie and Ted's infant is
organized? - ✔✔Marnie and Ted's infant is a healthy term infant which is the first
assessment that supports organization. I would assess physiologic function by
assessing vital signs. If the infant is organized I would observe, stable vital sign, good
