NR 203 Practice Exam with Accurate Answers.
Latest Edition
Late preterm - ✔✔34-36 6/7 weeks
At risk for:
-respiratory distress
-thermoregulation issues
-hypoglycemia
-hyperbilirubinemia
-feeding difficulties
-acidosis
-sepsis
Nursing care for thermoregulation issues - ✔✔check temp Q4
skin to skin
radiant warmer (if necessary)
Feeding issues in late preterm infants - ✔✔immature suck reflex
increased calorie need (feed Q2-3 hrs)
monitor suck/swallowing
Hypoglycemia in late preterm infants - ✔✔immature system
low birth weight
feeding difficulties
glucose checks
,Signs of hypoglycemia - ✔✔poor temp control
jittery
high pitched cry
(dont d/c before 48 hrs- need to be feeding well, good temp, bill levels normal)
S/S of preterm infants - ✔✔frail, weak, decreased muscle tone, large head, skin red and
transparent (lack of subcutaneous fat), abundant lanugo and vernix, little cartilage in pinnae of
ear
Signs of dehydration in the newborn - ✔✔urine output <2mL/kg/hr
urine specific gravity >1.01
wt loss greater than expected
dry skin/ mm
sunken anterior fontanel
poor tissue turgor
labs: ELEVATED Na, protein, and Hct
Signs of over hydration in the newborn - ✔✔urine output >5mL/kg/hr
urine specific gravity <1.002
edema
wt gain greater than expected
bulging fontanels
moist breath sounds
difficulty breathing
labs: DECREASED Na, protein, and Hct
signs of apnea - ✔✔not breathing for 20+ sec WITH cyanosis
,signs of periodic breathing - ✔✔not breathing for 5-10 sec followed by rapid respirations
(normal) with no other associated symptoms
Signs of inadequate temp control - ✔✔poor feeding, irritability followed by lethargy, weak
cry/suck, decreased muscle tone, hypoglycemia, or respiratory distress
signs of overstimulation in preterm infants - ✔✔changes in VS
cyanosis
pallor/mottling
nasal flaring
sneezing
coughing
behavioral changes of overstimulation - ✔✔stiff extended arms or legs
arching
turning away from eye contact
yawning
fatigue
how much should be given in enteral feedings - ✔✔105-130 kcal/kg/day
Signs baby is ready for nipple feedings - ✔✔rooting reflex
active sucking
RR <60
gag reflex
, respiratory distress syndrome - ✔✔The condition resulting from inadequate production of
surfactant and the resultant collapse of alveoli is
usually occurs within first hours after birth
S/S of respiratory distress syndrome - ✔✔tachypnea
nasal flaring
retractions
cyanosis
grunting
decreased breath sounds
acidosis (d/t hypoxemia)
Intraventricular hemorrhage (IVH) - ✔✔bleeding within a ventricle of the brain
Caused by:
high or low BP
asphyxia
respiratory distress (w/ mechanical vent.)
rapid blood volume expansion
acidosis
hypoglycemia
Graded 1-3 (1= very little bleeding)
s/s of intraventricular hemorrhage - ✔✔may have none or
lethargy
poor tone
Latest Edition
Late preterm - ✔✔34-36 6/7 weeks
At risk for:
-respiratory distress
-thermoregulation issues
-hypoglycemia
-hyperbilirubinemia
-feeding difficulties
-acidosis
-sepsis
Nursing care for thermoregulation issues - ✔✔check temp Q4
skin to skin
radiant warmer (if necessary)
Feeding issues in late preterm infants - ✔✔immature suck reflex
increased calorie need (feed Q2-3 hrs)
monitor suck/swallowing
Hypoglycemia in late preterm infants - ✔✔immature system
low birth weight
feeding difficulties
glucose checks
,Signs of hypoglycemia - ✔✔poor temp control
jittery
high pitched cry
(dont d/c before 48 hrs- need to be feeding well, good temp, bill levels normal)
S/S of preterm infants - ✔✔frail, weak, decreased muscle tone, large head, skin red and
transparent (lack of subcutaneous fat), abundant lanugo and vernix, little cartilage in pinnae of
ear
Signs of dehydration in the newborn - ✔✔urine output <2mL/kg/hr
urine specific gravity >1.01
wt loss greater than expected
dry skin/ mm
sunken anterior fontanel
poor tissue turgor
labs: ELEVATED Na, protein, and Hct
Signs of over hydration in the newborn - ✔✔urine output >5mL/kg/hr
urine specific gravity <1.002
edema
wt gain greater than expected
bulging fontanels
moist breath sounds
difficulty breathing
labs: DECREASED Na, protein, and Hct
signs of apnea - ✔✔not breathing for 20+ sec WITH cyanosis
,signs of periodic breathing - ✔✔not breathing for 5-10 sec followed by rapid respirations
(normal) with no other associated symptoms
Signs of inadequate temp control - ✔✔poor feeding, irritability followed by lethargy, weak
cry/suck, decreased muscle tone, hypoglycemia, or respiratory distress
signs of overstimulation in preterm infants - ✔✔changes in VS
cyanosis
pallor/mottling
nasal flaring
sneezing
coughing
behavioral changes of overstimulation - ✔✔stiff extended arms or legs
arching
turning away from eye contact
yawning
fatigue
how much should be given in enteral feedings - ✔✔105-130 kcal/kg/day
Signs baby is ready for nipple feedings - ✔✔rooting reflex
active sucking
RR <60
gag reflex
, respiratory distress syndrome - ✔✔The condition resulting from inadequate production of
surfactant and the resultant collapse of alveoli is
usually occurs within first hours after birth
S/S of respiratory distress syndrome - ✔✔tachypnea
nasal flaring
retractions
cyanosis
grunting
decreased breath sounds
acidosis (d/t hypoxemia)
Intraventricular hemorrhage (IVH) - ✔✔bleeding within a ventricle of the brain
Caused by:
high or low BP
asphyxia
respiratory distress (w/ mechanical vent.)
rapid blood volume expansion
acidosis
hypoglycemia
Graded 1-3 (1= very little bleeding)
s/s of intraventricular hemorrhage - ✔✔may have none or
lethargy
poor tone
