NUR 106 Practice Exam Questions and Correct Answers
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Course
NUR 106
Institution
NUR 106
When does the nurse perform the APGAR assessment? at one minute & at 5 min of NB life
What is the priority vital sign to obtain on a NB? RR (*30-60/min*)
*irregular *abdominal breathers *5-10 sec pause is okay but concerned if *apnea = longer than 20 sec pause without breathing by themselves*
Wh...
NUR 106 Practice Exam Questions and
Correct Answers
When does the nurse perform the APGAR assessment? ✅at one minute & at 5 min of
NB life
What is the priority vital sign to obtain on a NB? ✅RR (*30-60/min*)
*irregular
*abdominal breathers
*5-10 sec pause is okay but concerned if *apnea = longer than 20 sec pause without
breathing by themselves*
What creates the first breath that initiates life of the NB outside the womb? ✅-
respiratory acidosis (creates *need* to draw first breath)
-NB goes into temp that is 10-20 degrees colder than it is used to and it creates a
*shock* which = deep breath
-transitory asphyxia
What happens when the oxygen supply that was being supplied to the fetus through the
umbilical cord is cut off? ✅transitory asphyxia (NB realizes they are oxygen deprived
and it creates the need to take in a deep breath and initiate life)
Before performing the APGAR assessment, what does the nurse do first? ✅-ensure
patent airway (bulb syringe)
-clean up & dry off/warm up NB (*60 seconds to calm down and ensure systems are
working*)
What is the highest score a NB can receive on the APGAR? ✅10 (but rare)
Regarding the APGAR score, what would indicate a score of "1" for HR? ✅below
100/min
The NB received a score of "2" on their APGAR score for HR, what would this indicate?
✅100/min or higher
Regarding the APGAR score, what would indicate a score of "0" for HR? ✅Absent HR
What would indicate a score of "0" on the APGAR score for respiratory effort? ✅No
spontaneous respirations
If APGAR scores are low, when do you perform the assessment again? ✅at 10 min of
NB life (to show that you intervened/transitioned appropriately - ex. Didn't leave delivery
room with a score of 6)
,What does an APGAR score of *0-3* indicate for the NB? ✅-*distress*
-not breathing/decreased respiratory effort
-not circulating
-limp
-*MOST LIKELY TO HAVE PERMANENT NEURO DEFICIT*
-*HIGHEST MORTALITY*
-usually admitted straight to NICU to be put on ventilator
-*requires respiratory intervention*
*commonly premies (20-28wks) because immature lung development*
What does an APGAR score of *4-6* indicate for the NB? ✅-moderate difficulty
-could still potentially require resp. Intervention (ventilator)
-*can bounce back after RR & O2 increases*
*monitor ventilation b/c can still have mortality*
What does an APGAR score of *7-10* indicate for the NB? ✅-absence of difficulty *AT
THAT TIME*
Why does the nurse hang the baby upside down and slap its back after delivery? ✅to
elicit crying which would cause deep breaths & therefor *clear our amniotic fluid &
initiate breathing* (along with gravity)
How often are NB VS taken? ✅q 4 hrs (but monitor closely first 24 hrs of life because
they are the most difficult for the NB)
*can be taken by:*
-RN
-RN student
-OB tech
Apnea in the NB doesn't just indicate respiratory function, it could also indicate what?
✅-prematurity
-NB is cold
-NB has low BS
How long does the RN count HR and RR in the NB? ✅one full minute - due to
irregularity and pauses that are common with NB
What is expected about the NB HR? ✅-common to what it was in utero
-*110-160 bpm* (very fast)
, -may hear *soft systolic murmur* (due to turbulent blood flow in the openings of the NB
heart -*shunted straight from Rt. To Lft. Side of heart*)
What is the expected temp. Of a NB? ✅97.8-98.8
How do you elicit the swallowing reflex and what is the expected outcome? ✅place
fluid on the back of tongue
-infant swallows fluid (should be coordinated with sucking)
*present throughout life*
Why do premature NB have a high risk for hypothermia (becoming cold)? ✅-inability to
thermoregulate (*can't shiver*)
-lack of brown fat (warms blood as it circulates through it)
*so RN/family has to warm them up*
-thermoregulation occurs only after 38weeks (full term)
What does the RN do if they find that the NB temp is abnormal when obtaining VS
(assessment wise)? ✅-check again to verify (other axillary)
-identify potential contributors and intervene accordingly (ex. Cold environment)
-*assess skin*: (is it cold to touch? Is it mottling?)
-make sure NB has been covered up & warm (ask fam if NB has been naked)
What does the RN do if the NB is cold (interventions)? ✅-swaddle & put on hat
-educate mother about importance of keeping baby swaddled/covered
-skin-to-skin contact to transfer heat & cover both with blankets)
-wait 30-45 min & recheck temp. (if still low, indicates more serious prob so contact
neonatal NP)
Neonatal NP:
-puts under *radiant warmer* (typically in nursery)
-puts baby in thicker, more extensive swaddling
What happens to the NB temperature when they get infections? ✅temp *drops*
(so, RN is more concerned with temp. Decreases than temp. Elevations)
Where does the RN assess for temp. In a NB? ✅*axillary* (unless otherwise stated)
-have to hold the infant's arm in place to keep the probe from moving
What is the *internal* stimuli that causes the infant to draw its first breath? ✅-
decreased PO2
-decreased ph (resp. Acidosis)
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