NBCRNA HELP - SPECIAL POPULATIONS NEW SET WITH ALL QUESTIONS AND CORRECT ANSWERS, Exams of Nursing

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NBCRNA HELP - SPECIAL POPULATIONS NEW SET WITH ALL QUESTIONS AND CORRECT ANSWERS 100% VERIFIED 2026-2027!! Obstetric >> Respiratory Changes - ANSWER Upper Airway = >> increased progesteron, estrogen, + relaxin = vascular engorgement + hyperemia >increased extracellular fluid >>airway swelling -- increased mallampati, difficult intubation, narrowed glottic opening lungs = >> increased anterior-posterior diameter of chest >> gives lungs more space >> diaphragm goes cephalad -- reduced FRC, reduced RV, reduced ERV -- increased O2 consumption -- FRC falls below CC = airway closure during tidal breathing -- no change in vital capacity Arterial blood gas = >> progesterone = resp stimulant >> minute ventilation increases up to 50% >> decreases CO2 >> resp alkalosis >> renal compensation eliminates bicarb -- increased PaO2 d/t hyperventilation -- even though resp alkalosis, oxyhgb curve goes RIGHT to facilitate O2 transfer to fetus -- Minute ventilation = increased rate + Tv Obstetrics >>> Cardiovascular Changes - ANSWER -- CO - 40% increase di/t increase in HR+ SV -- no change in SBP. but DBP goes down d/t decreased SVR -- no change in map because of the increase in blood volume -- decrease SVR + PVR because progesterone increases NO and decreases response to angiotensin and NE aortocaval compression = syndrome of supine hypotension >> gravid uterus compresses both the vena cava and the aorta >> decreases venous return to heart as well as arterial flow to the utuerus + LE >> elevate right side 15-30° during 2nd or 3rd trimester Hematologic = >> 45% increase in plasma volume >> 20% increase in erythrocytes >> dilutional anemia >> clotting factors = increase in 1, 7, 8, 9, 10, 12 and decrease in 11 + 13 --- hypercoagulable state >> decrease antithrombin and protein S >> increase in fibrin breakdown -- PT and PTT decrease 20% -- pit unchanged Obstetrics >>> Neuro changes - ANSWER MAC >> decreases 30-40% (progesterone) sensitivity to LA >> increases (progesterone) epidural vein volume >> increases - decreased volume of subarachnoid + epidural spaces because of compressive effect no change in ICP Obstetric >> GI changes - ANSWER gastric volume = increase (increased gastrin) gastric pH = decreases (increases gastrin) LES sphincter tone = decreases (increased progesterone + estrogen, cephalad displacement of diaphragm gastric emptying = no change before labor Obstetric >> renal changes - ANSWER GFR = increases (increased blood volume + CO) Creatinine Clearance = increases (increased blood volume + CO) Glucose in urine = increases (increased GFR + decreased renal absorption) Creatinine + BUN = decreased (increased CC) Obstetrics >> other changes - ANSWER uterine blood flow = increases (up to 700- 900 mi/min >> 10% of CO) serum albumin = decrease >> increased free fraction of highly protein bound drugs pseudocholinesterase = decreases (no meaningful effect on succ metabolism) Uterus - ANSWER BF non pregnant = 100 ml/min pregnant at term = 700-900 mi/min --uterus + cervix = neuraxial, paravertebral lumbar sympathetic block, paracervical block --perineum = neuraxial or pudendal nerve block fetal heart rate - ANSWER >> the fetus responds to stress with peripheral vasoconstriction, htn, and a barareceptor-mediated reduction in HR >> normal = 110-160 (intact CNS, ANS, normal acid-base, normal uteroplacental perfusion) >> brady = <110 = asphyxia, acidosis, maternal hypoxemia, drugs that decrease uteroplacental perfusion >> tachy = > 160 = fetal hypoxemia+ arrythmias, maternal fever, chorioamnionitis, atropine, ephedrine, terbutaline Baseline HR variability = >> normal/moderate = 6-25 bpm >> minimal = <5 >> marked = >25 >>absent = a worrisome finding -- things that reduce variability = CNS depressant drugs, hypoxemia, fetal sleep, acidosis, anencephaly, cardiac anomalies Category 1 - strongly suggests normal acid-base status with no threat to fetal oxygenation >> baseline HR 110-160, moderate variability, accelerations absent or present, early decelerations absent or present, no late or variable decelerations Category 2 - is not 1 or 3 and cannot predict a normal or abnormal acid-base statuse >> brady without the absence baseline FHR variability, tachy, variable variability, absent or minimal acceleration with fetal stimulation, recurrent variable decelerations Category 3 - strongly suggests abnormal acid-base status with significant threat to fetal oxygenation >> brady, absent baseline variability, recurrent late deceleration, recurrent variable deceleration, sinusoidal pattern Early Decelerations - Fetal Heart Rate - ANSWER >> head compression >> NO RISK OF FETAL HYPOXEMIA >> uterine contractions compresses fetal head >> head compression increases vagal tone (HR < 20 from baseline) >> onset and offset parallel to uterine contraction >> loses variability with each deceleration Late Decelerations - Fetal Heart Rate - ANSWER >> UTEROPLACENTAL INSUFFICIENCY > compression of vessels **risk for fetal hypoxemia, requires urgent assessment of fetal status -- decreased uteroplacental perfusion leads to fetal compromise -- FHR falls after peak of contraction then returns to baseline after contraction -- gradual (not abrupt) reduction in FHR -- caused by maternal hypotension, hypovolemia, acidosis, preeclampsia Variable decelerations - fetal heart rate - ANSWER UMBILICAL CORD COMPRESSION >> risk for fetal hypoxemia - requires urgen assessment of fetal status - no consistent pattern between FHR and contraction - umbilical compression causes baroreceptor mediated reduction in FHR - decelerations are usually self-limiting - maintains variability during deceleration - fetal compromise prolongs FHR recovery time VEAL CHOP Variable decels > Cord compression Early decels > Head compressioin Accelerations > Okay or give Oxygen Late decels > Placental insufficiency prematurity - ANSWER delivery before37 weeks gestation leading cause of perinatal morbidity and mortality complications - respiratory distress syndrome, intraventricular hemorrhage, NEC, hypoglycemia, hypocalcemia, hyperbilirubinemia >> corticosteroids are given to hasten fetal lung maturity (18 hours to work with a peak of 48 hours) >> tocolytics = delay labor by suppressing uterine contractions >> Beta 2 stimulation = increased cAMP >> turns on protein kinase >> turns off myosin light chain kinase >> relaxes uterus >> increases progesterone release - side effects = hyperglycemia (glycogenolysis), hypokalemia from intracellular k shift, Beta 2 agonists cross the placenta and may increase FHR triple prophylaxis against aspiration = sodium citrate to neutralize gastric acid, H2 receptor antagonist to reduce gastric acid secretion, gastrokinetic agent to hasten gastric emptying and increase LES tone Obstetric Hypertensive Disorders - ANSWER Chronic HTN = develops before 20 weeks, does not go away s/p delivery Gestational HTN = develops after 20 weeks -- no proteinuria, goes away s/p delivery Preeclampsia = htn s/p 20 weeks, proteinuria, persistent RUQ or epigastric pain, persistent CNS or visual symptoms (H/A, hyperreflexia, hyperexcitability, coma), fetal growth restriction, thrombocytopenia, elevated serum liver enzymes >> those with CKD or + for antiotensinogen T235 allele have highest risk -- the healthy placenta produces thromboxane and prostacyclin in equal amounts >> pt with preeclampsia produces up to 7 times more thromboxane than prostacyclin = vasoconstriction, pit aggregation, and reduced placental blood flow Severe Preeclampsia = when BP exceeds 160/110 Eclampsia = occurs when mother with preeclampsia develops seizures Abnormal Placental Implantation - ANSWER >> normal = placenta implants into dicidua of the endometrium >> accreta = attaches to the surface of the myometrium >> Increta = invades the myometrium >> percreta = extends beyond uterus -- uterine contractility is impaired = tremendous potential for blood loss -- closely associated with placenta previa + previous c-sections placenta previa - ANSWER placenta attaches to the lower uterine segment and partially or completely covers the cervical os - PAINLESS vaginal bleeding - potential for hemorrhage risk factors = previous c-sections, hx of mx births placental abruption (abruptio placentae) - ANSWER partial or complete separation of placenta from uterine wall before delivery risk factors = Pregnancy induced HTN, preeclamspia, chronic HTN, cocaine use, smoking, excessive etoh use PAINFUL vaginal hemorrhage risk of amniotic fluid embolism >> DIC postpartum hemorrhage - ANSWER -- uterine atony is the most common cause of postpartum hemorrhage >> risk increased by: multiparity, mx gestations, plyhydramnios, prolonged oxytocin infusion other causes = retained placenta (nitroglycerin provides uterine relaxation for placental extraction), laceration to the cervix or vaginal wall, uterine inversion, coagulopathy, placenta previa, placental abruption, abnormal placental implantation DIC is associated with = amniotic fluid embolism, placenta abruption, intrauterine fetal demise >> often accompanied by circulatory shock Apgar - ANSWER 5 parameters are measured at 1 minute and 5 minutes s/p delivery normal = 8-10, mod distress = 4-7, impending demise = 0-3 Heart rate>> absent = 0, < 100 = 1, > 100 =2 Respiratory effort >> absent = 0, slowtirregular = 1, normal, crying = 2 muscle tone >> limp = 0, some flexion of extremities = 1, active motion = 2 reflex irritability >> absent = 0, grimace = 1, cough, sneeze, cry = 2 color >> pale, blue = 0, body pink, extremities blue = 1, completely pink = 2 - score at 1 minute correlates with acid-base status - 5 minute score may be predictive of neurologic outcome Neonate = Vital Signs - ANSWER neonate = first 28 days of life infant = 28 days > 1 year Newborn = - SBP =70 - DBP = 40 Neonate - Oxygen Demand, Supply + Reserve - ANSWER -- distal saccules of the of the lung begin to develop alveoli between 24-28 weeks of gestation, and the alveoli continue to rise throughout childhood until 8-10 years of age -- alveolar surface 1/3 of an adults but O02 consumption is 2-3 times higher >>> the require higher alveolar ventilation to sustain normal arterial gas tensions >> increase respiratory rate -- oxygen consumption = 6-9 ml/kg/min (adult is 3.5) -- alveolar ventilation = 130 mi/kg/min (adult is 60 ml/kg/min) -- RR = 35 bpm (adult 15) -- Vt=6 mi/kg neonate - muscles of inspiration - ANSWER - diaphragm primary muscle of inspiration - intercostals are inadequately developed - type 1 muscles = slow twitch (endurance) - type 2 muscles = fast twitch (short bursts) - neonatal diaphragm only has 25% type 1 (adults have 55%) -risk of postop apnea = inversely related to gestational and post-conceptual age neonate - pulmonary mechanics - ANSWER -- in the adult = chest wall tends to expand and the lungs tend to collapse (negatrive pressure in pleural space) -- the newborn = lower compliance d/t fewer alveoli + higher chest wall compliance d/t cartilaginous ribcage that gives less structural support >> Closing capacity overlaps with tidal volum during normal breathing = V/Q mismatch, increased A-a gradient, predisposes the newborn to hypoxemia - neonates have lower FRC, lower VC, lower TLC, higher residual volume, higher closing capacity, same tidal volume -- work of breathing is increased d/t increased airway resistance >> air has to overcome this resistance + the elastic properties of the chest and lungs Mother + Fetus = Blood Gases - ANSWER pH = > Mother at term = 7.4 > Umbilical Vein: Placenta >> Fetus = 7.35 > Umbilical arteries : Fetus >> Placenta = 7.30 > newborn at time after delivery = -10 min =7.2 -1hr= 7.35 - 24 hr = 7.35 PaO2 = > Mother at term = 90 > Umbilical Vein: Placenta Fetus = 30 > Umbilical arteries : Fetus Placenta = 20 > newborn at time after delivery = - 10 min = 50 -1hr=60 - 24 hr =70 PaCO2 = > Mother at term = 30 > Umbilical Vein: Placenta Fetus = 40 > Umbilical arteries : Fetus Placenta = 50 > newborn at time after delivery = - 10 min = 50 -1hr=30 - 24 hr = 30 -- clamping of the umbilical cord and the acute rise in PaO2 promotes continuous breathing and hypoxemia promotes apnea >> respiratory control doesn't mature until 42-44 post conceptual age so hypoxemia depresses ventilation until it matures -- the newborn comes into the world hypoxic, acidotic, and retaining CO2 Fetal Hemoglobin - ANSWER >> normal P50 = 26.5 >> fetal hgb P50 = 19 (has a higher affinity for oxygen because it cannot bind 2,3- DPG) - by 6 months Hgb F as been replaced Tranfusions in babies - ANSWER 1a = erythrocyte transfusion for children less than 4 months >> transfer trigger of < 13 in the child with severe cardiopulmonary disease >> transfer trigger < 10 in the child presenting for major surgery or with moderate cardiopulmonary disease >> dose = 10-15 mL/kg >> 10 ml/kg will raise hgb by 1-2 1b = Erythrocyte transfusion for children older than 4 months >> by this age, Hgb A are beginning to proliferate and these cells have a lower affinity to oxygen >> transfusion is rarely indicated if Hgb > 10 >> renal tubular function continues to improve after birth but it does not achieve full concentrating ability until ~ 2 years Body Water Distribution - Neonate - ANSWER Adult water distribution = TBWIICF/ECF = 60/40/20 Child = 60/40/20 neonate = 75/35/40 premature = 85/25/60 >> babies = the ECF is larger than the ICF >> signs of dehydration = - sunken anterior fontanel - weight loss - irritability or lethargy - dry mucous membranes - absence of tears - decreased skin turgor - increased hct in the absence of transfusion Fluid Management - 4:2:1 - ANSWER 1. 4:2:1 rule 2. NPO deficit calculation (replace over 3 hours > 50%,25%,25% 3. 3rd space loss calculation (minimal = 3-4, moderate = 5-6, major = 7-10) 4. blood loss = crystalloid 3:1, colloid = 1:1 which fluid? >> 0.9% NaCl, plasma-lyte, 5% albumin >> use of glucose containing solutions is not recommended unless at risk for hypoglycemia (premature, less than 48H, small for gestational age, newborns of diabetic mothers, diabetic children, children who receive glucose-based parenteral nutrition) signs of hypoglycemia in newborn = develop around 40, GA masks symptoms, Neonate pharmacokinetics + Pharmacodynamics - ANSWER - CO for a newborn = 200 mi/kg >> drugs are delivered to and removed from the body at a faster rate than adults - volume of distribution = >> higher TBW = higher doses of water soluble drugs to achieve plasma concentration - protein binding = >> before 6 months, there are lower concentrations of albumin + alpha-1 acid glycoprotein, so drugs that are usualy highly protein bound, the neonate will experience increased free drug levels and have a higher risk for toxicity - adipose content = >> neonates have a higher percentage of TBW and lower percentage of fat + muscle mass = drugs that require fat for redistribution and termination of effect have a longer duration of action - hepatic metabolism = >> drug biotransformation reactions are underdeveloped for the first month >> neonate cannot conjugate bilirubin - renal clearance = >> normal GFR ~8-24 months >> normal tubular function ~ 2 years - BBB= >> immature = allows drugs that would otherwise not be able to enter the brain >> explains a higher sensitivity to sedative-hypnotics - MAC = >> neonate = mac is lower than infant >> premature = mac is lower than neonate >> infant 1-6 months - MAC is higher than adult >> infant 2-3 months = MAC peaks at highest level neonates = NMB - ANSWER - neonates have more TBW, BUT, their neuromuscular junction is immature and is more sensitive to non-depolarizing NMBs and equally sensitive to succinylcholine >> this necessitates a higher dose of succ but the dose for NDNMB = the same as adults Succinylcholine = >> in children < 5 = bradycardia or asystole >> IM dose = 5/kg for neonates, 4/kg for bigger kids Rocuronium = >> dose = 0.6-1.2 mg/kg >> metabolized by liver >> can be given IM as well 1 mg/kg <1 year, 1.8 mg/kg > 1 year Esophageal Atresia - ANSWER ** esophageal atresia is the most common congenital deficit of the esophagus, and most of these children also have a trachoesophageal fistula - hypoxemia > acidosis > possibly return to fetal circulation - risk factors = low birth weight, low gestational age, barotrauma from positive pressure, oxygen toxicity, endotracheal intubation, maternal diabetes >> amniocentesis = ratio of lecithin to sphingomyelin (L/S ratio) = gives advanced warning about state of fetal lung -- > 2 = adequate lung development -- <2 = associated with increased risk of respiratory distress syndrome >>SpO2 should be maintained while keeping in mind that hyperoxia is one factor that may contribute to retinopathy of prematurity >> >> preductal + postductal oximeter should be used -- preductal = RUE -- postductal = LE >> difference between values = pulmonary htn, right to left shunt, return of fetal circulation via PDA Congenital Diaphragmatic hernia - ANSWER >> a diaphragmatic defect that allows the abdominal contents to enter the thoracic cavity -- foramen of Bochdalek is most common site of herniation (usually left side) >> diagnosed at birth = newborn will have respiratory distress + scaphoid abdomen (sunken in) - other findings = barrel chest, cardiac displacement, fluid filled Gl segments in thorax - consequences of abdominal contents in chest = >> pulmonary hypoplasia >> poor pulmonary vascular development, increased PVR, pulmonary htn, impaired airway development, airway reactivity >> keep PIP < 25-30 to minimize barotrauma + pnx >> avoid things that increase PVR (hypoxemia, acidosis, hypothermia) Omphalocele + Gastroschisis - ANSWER >>> most common congenital abdominal wall defects >>> OMPHALOCELE = caused by failure of gut migration from yolk sac into the abdomen >>> GASTROSCHISIS = caused by occlusion of the omphalomesenteric artery during gestation = the viscera + intestines herniat on the RIGHT of the umbilicus OMPHALOCELE = > Location of defect - Midline - involves umbilicus > organ involvement - bowel and sometimes liver > covering? - yes > incidence - 1: 5,000 > co-existing diseases - Trisomy 21, cardiac defects, beckwith-wiedemann syndrome > surgery - less urgent, requires cardiac workup > primary closure - prosthetic silo, may be staged GASTROSCHISIS = > Location of defect - off midline - usually to the right of the umbilicus > organ involvement - bowel > covering? - no > incidence - 1:2,000 > co-existing diseases - prematurity > surgery - more urgent (within 24H), at higher risk of fluid and heat loss, IVF = 150-300 mi/kg/day > primary closure - prosthetic silo, may be staged anesthetic management = > monitor peak airway pressure >> if PIP is > 25-30, surgical closure may need to occur in stages > increased abdominal pressure > decrease venous return > decreased CO > decreased systemic perfusion > measure SpO2 on the lower extremity to monitor for impaired venous return Pyloric Stenosis - ANSWER >> occurs when hypertrophy of the pyloric muscle creates a mechanical obstruction at the gastric outlet between the stomach and the duodenum -- and olive shaped mass can be palpated just below the xiphoid process PRESENTATION = non-bilious projectile vomiting, occurs within 2-12 weeks of life, more common in males, not typically associated with other congenital issues patho = >> vomiting = depleted water, hydrogen, chloride, sodium, and potassium -- dehydration + hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis (left shift) + compensatory respiratory acidosis >> kidneys compensate for metabolic alkalosis by increases bicarb excretion = alkalotic urine >> as dehydration continues = kidneys retain Na + water d/t increased aldosterone = kidneys lose H >> paradoxical acidification of urine >> if dehydration is not corrected, impaired tissue perfusion = increases lactic acid production (LATE COMPLICATION) risk factors = prematurity, low plasma protein concentration, acidosis treatment = phototherapy + exchange transfusion (rarely needed) fetal circulation - ANSWER **SHUNT DEPENDENT Unique structures and their functions = >> placenta = were gas exchange occurs >> umbilical VEIN (1) = carries OXYGENATED blood from mother to fetus >> umbilical ARTERIES (2) = carries DEOXYGENATED blood from fetus to mother >> ductus VENOSUS = shunts blood from the umbilical vein to the IVC (BYPASSES LIVER) >> foramen OVALE = shunts blood from the RA to the LA (BYPASSES LUNGS) >> ductus ARTERIOSUS = shunts blood from the PA to the aorta (BYPASSES LUNGS) fetal circulation differs from the adult circulation in 6 ways: 1. the placenta is the organ of respiration (adult = lungs) 2. circulation is arranged in parallel (adult = series) 3. right to left shunting occurs across the FO+ DA 4. SVR = low (placenta provides a large, low resistance vascular bed) 5. PVR = high (lungs are collapsed and filled with fluid so there is very little pulmonary BF) 6. minimal pulmonary blood flow and left atrial pressure is low PATHWAY = 1 umbilical vein >> oxygenated blood from Ductus venosus (past liver) + deoxygenated blood from LE >> IVC >> higher velocity blood from ductus >> RA (Eustachian Valve) >> Foramen Ovale >> LA >> myocardium + developing brain >> lower velocity blood from LE >> RV + Pulmonary trunk >> Ductus Arteriosus >> proximal descending aorta >> LE >> placenta via 2 umbilical arteries Fetal Circulation >>> Extrauterine Life - ANSWER 1. first breath = lung expansion >> increased PaO2 + decreased PaCO2 >> decreased PVR 2. placenta separates from uterine wall >> increased SVR 3. decreased PVR + increased SVR = LA pressure > RA pressure >> Foramen Ovale closes 4. decreased PVR >> reversal of blood flow through ductus arteriosus >> exposes DA to increased PO2 >> DA closure 5. decreased circulating PGE1 (released from placenta) >> DA closure ** a DA that remains open = continuous systolic and diastolic murmur fetal shunts - ANSWER 1. Foramen Ovale = >> Purpose: RA >>LA >> Functional closure: LAP > RAP (umbilical cord clamping leads to increased SVR) >> Anatomic closure: 3 days >> Adult remnant: Fossa ovalis >> Key points: ~ 30% of adults = increased risk of paradoxical embolism (travels to brain instead of lungs) 2. Ductus Arteriosus = >> Purpose: pulmonary trunk >> aorta >> Functional closure: SVR > PVR (increased PaO2 and decreased prostaglandins from the placenta) >> Anatomic closure: several weeks via fibrosis >> Adult remnant: ligamentum arteriosum >> Key points: PDA can be closed with indomethacin (prostaglandin synthase inhibitor), can be opened with prostaglandin E1 (PGE‘1), plays a key role in trauma where rapid deceleration tears the ligament resulting in partial or complete aortic dissection 3. Ductus Venosus = >> Purpose: allows umbilical blood to bypass the liver >> Functional closure: umbilical cord clamping >> Adult remnant: ligamentum venosum >> Key points: the ligamentum venosum cannot reopen Vascular Resistance: PVR + SVR - ANSWER **shunting occurs when there is an abnormal communication between the pulmonary and systemic circulations ** the size and direction of the shunt are dependent on 3 factors: 1. ratio of PVR to SVR - -- R >> L shunt occurs when PVR is greater than SVR -- L>> R shunt occurs when SVR is greater than PVR >>> vascular resistance is like a gatekeeper to ventricular ejection = blood follows the path of least resistance, so high vascular resistance increases the amount of blood that passes through the shunt 2. Pressure gradients between the cardiac chambers or arteries involved 3. compliances of the cardiac chambers Pulmonary Vascular Resistance - ANSWER Things that increase: > Hypercarbia > hypoxemia > acidosis