Final Exam - Misc. Flashcards
What factors define pathologic hyperbilirubinemia?
- Serum bilirubin above 95th percentile
- Jaundice that develops in the first 24 hr
- Rise in serum bilirubin >2 mg/dL/hr,
- Jaundice that persists >2 weeks in term infant
What is the overarching cause of pathologic hyperbilirubinemia?
Most common causes: disease processes that ↑ hemolysis and ↑ bilirubin production.
What are the specific processes that can cause pathologic hyperbilirubinemia?
- ABO incompatibility
- Known hemolytic disease of the newborn
- ↑ RBC breakdown from cephalohematoma or polycythemia (post-maturity, maternal diabetes, twin-to-twin transfusion, low fetal O2 levels)
- Sepsis
- Extensive bruising
- Poor breastfeeding
What conditions can lead to polycythemia in a newborn that lend to hyperbilirubinemia?
Post-maturity
Maternal diabetes
Twin-to-twin transfusion
Low fetal O2 levels
What is polycythemia?
An increase in the absolute red blood cell mass in the body.
What condition in the newborn is possibly caused by the following conditions?
Post-maturity
Maternal diabetes
Twin-to-twin transfusion
Low fetal O2 levels
Polycythemia
What condition in the newborn is caused by polycythemia?
Hyperbilirubinemia
What lever of serum bilirubin can cause cell death and necrosis?
Serum bilirubin levels >25 mg/dL can cause cell death and necrosis.
What is BIND?
Bilirubin-induced neurologic dysfunction (BIND) whereby bilirubin crosses blood-brain barrier & binds to brain tissue.
What happens in BIND?
Bilirubin crosses blood-brain barrier & binds to brain tissue.
What is the clinical manifestations of BIND?
Acute bilirubin encephalopathy (ABE) = the clinical manifestations of BIND. ABE may be permanent or reversible.
What is ABE?
Acute bilirubin encephalopathy.
Is ABE permanent or reversible?
Can be either.
What is kernicterus?
Kernicterus = permanent, irreversible effects of BIND (usually ABE s/s first)
Risk for kernicterus increases as serum bilirubin levels increase (>25 = 6%, >30 = 14-25% risk)
Nearly all infants with bili >35 have kernicterus
What is the level of bilirubin that is the risk for kernicterus?
Nearly all infants with bili >35 have kernicterus
The risk for kernicterus increases with what?
Risk for kernicterus increases as serum bilirubin levels increase (>25 = 6%, >30 = 14-25% risk)
What is the progression in a neonate for bilirubin levels >25 mg/dL?
- BIND - Bilirubin-induced neurologic dysfunction (bilirubin binding to brain tissue)
- ABE - Acute Bilirubin Encephalopathy (clinical manifestations of BIND)
- Possibly Kernicterus
(irreversible effects of BIND)
Symptoms of BIND
Lethargy
Fever
Irritability
Jitteriness
Hypotonia
Poor feeding
Apnea
Seizures
High-pitched cry
Symptoms of Kernicterus
Cerebral palsy
Sensorineural hearing loss
Gaze abnormalities
Dental enamel dysplasia
What condition in the neonate are the following symptoms of?
Cerebral palsy
Sensorineural hearing loss
Gaze abnormalities
Dental enamel dysplasia
Kernicterus
What condition are the following symptoms of in the neonate?
Lethargy
Fever
Irritability
Jitteriness
Hypotonia
Poor feeding
Apnea
Seizures
High-pitched cry
BIND
What is the treatment for infants with BIND and ABE?
Infants w/ BIND and ABE are treated with an exchange transfusion regardless of bilirubin levels.
T/F: Infants with BIND and ABE are treated with an exchange transfusion based on a bilirubin level > 35 mg/dL.
False. Infants w/ BIND and ABE are treated with an exchange transfusion regardless of bilirubin levels but definitely w/ serum bili ≥25 mg/dL with neurologic symptoms.
Nursing assessments for hyperbilirubinemia
- Visual inspection for jaundice
- Check ABO compatibility (maternal & newborn)
- Monitor serum bilirubin levels
- Maintain thermoregulation
- Assess for s/s of ABE
What are the parameters of phototherapy for jaundiced newborns?
- Continuous if serum bilirubin ≥20 mg/dL
- May be interrupted for feeding/bonding if serum bili <20 mg/dL)
What type of complication is Meconium Aspiration Syndrome (MAS)?
Pulmonary.
What is Meconium Aspiration Syndrome (MAS)?
Aspiration of meconium-stained amniotic fluid.
What complications result from MAS?
- Leads to respiratory disease, hypoxemia and acidosis
- Also caused by intrauterine stress
How is MAS diagnosed?
- S/S present w/in 15 minutes of birth
- Confirmed by chest x-ray
- Arterial blood gasses
Which infants are at greatest risk of MAS?
Greatest risk in infants that are post-term or SGA.
What are the interventions for a newborn with MAS?
O2 supplementation
Mechanical ventilation
Surfactant therapy
Nitric oxide
ECMO
Correction of metabolic abnormalities (acidosis, hypoglycemia)
Antibiotics as indicated
What condition in the newborn is treated with the following interventions?
O2 supplementation
Mechanical ventilation
Surfactant therapy
Nitric oxide
ECMO
Correction of metabolic abnormalities (acidosis, hypoglycemia)
Antibiotics as indicated
Meconium aspiration syndrome (MAS)
What is the cause of meconium aspiration syndrome (MAS)?
Chronic asphyxia and infection can lead to meconium staining of the amniotic fluid, which is then aspirated by the fetus.
For what condition in the newborn does the following cause?
Chronic asphyxia and infection can lead to meconium staining of the amniotic fluid, which is then aspirated by the fetus.
Meconium aspiration syndrome (MAS)
What are the S/S of meconium aspiration syndrome (MAS)?
Meconium stained amniotic fluid
Respiratory or neurologic depression at birth
Postmature or SGA
Cyanosis
Acidosis
Rales/rhonchi
Pneumothorax
What necrotizing enterocolitis?
Ischemic necrosis of the intestines
How emergent is necrotizing enterocolitis?
It’s a medical emergency
What newborns are at greatest risk for necrotizing enterocolitis?
Greatest risk in preterm, low birth weight infants, especially those under 1,500 gms.
What condition do these factors put a newborn at risk for?
Underdeveloped mucosa of intestines permeable to bacteria combined w/ immature immune response – unable to combat infection.
Necrotizing enterocolitis
What treatment is available for necrotizing enterocolitis?
Antenatal corticosteroid therapy and human breast milk are protective against NEC.
What is the first sign of necrotizing enterocolitis?
First sign of problem is usually feeding intolerance.
What are complications from necrotizing enterocolitis?
Complications: infection, sepsis, DIC, respiratory failure, and metabolic issues (hypoglycemia & metabolic acidosis).
What condition in the newborn has the following complications?
Complications: infection, sepsis, DIC, respiratory failure, and metabolic issues (hypoglycemia & metabolic acidosis).
Necrotizing enterocolitis
Interventions for necrotizing enterocolitis.
Bowel rest - d/c enteral feedings
NG suctioning for GI decompression
TPN for nutrition and fluids as needed
Cardiac support: meds to correct hypotension
May need respiratory support
For what condition are the following interventions?
Bowel rest - d/c enteral feedings
NG suctioning for GI decompression
TPN for nutrition and fluids as needed
Cardiac support: meds to correct hypotension
May need respiratory support
Necrotizing enterocolitis.
What will imaging show on an newborn with necrotizing enterocolitis?
Inflamed intestinal wall with gas bubbles.
What does exposure to tobacco in utero cause in a newborn?
Vasoconstriction
Neonates of mothers who smoke may display what?
More irritability & hypertonicity
Less able to self-soothe
Maternal tobacco abuse can cause what high risk conditions in pregnancy?
High risk for: preterm delivery, placental abruption, chorioamnionitis, preeclampsia, PPROM.
What are the risks to the newborn after delivery to a mother who abused tobacco during pregnancy?
Risks after delivery: SIDS, T2DM, behavioral problems (ADHD), asthma, may increase risk for schizophrenia and Tourette’s syndrome.
Smoking can negatively impact breastmilk production, taste & composition, leading to poor weight gain; infants tend to sleep poorly and for shorter duration.
What are the following conditions indicative of?
Risks after delivery: SIDS, T2DM, behavioral problems (ADHD), asthma, may increase risk for schizophrenia and Tourette’s syndrome.
Decreased breastmilk production, taste & composition, leading to poor weight gain; infants tend to sleep poorly and for shorter duration.
Maternal tobacco use.
What interventions are recommended for a pregnant mother who uses tobacco?
Care: encouraging smoking cessation (*or reduction), especially in 1st trimester, greatly reduces complications of pregnancy & risks to the newborn.
What newborn condition is associated with opioid use in the mother?
Neonatal Abstinence Syndrome (NAS)
When does opioid withdrawal start in a newborn?
Opioid withdrawal usually starts 48-72 hours after birth or up to 5 days after birth.
Opioid withdrawal affects what 4 domains?
State control and attention
Motor and tone control
Sensory integration
Autonomic functioning
What are the risks of opioid withdrawal in a neonate?
High risk for respiratory complications and seizures; SIDS after discharge .
What are the treatments for neonatal abstinence syndrome?
Opioids (morphine, methadone, buprenorphine) - weaned over time.
What are the supportive interventions for neonatal abstinance syndrome?
Swaddling, rocking, laid on side; minimize auditory, tactile and visual stimuli; pacifier for self-regulation; small, frequent feedings; encourage breastfeeding.
What are the S/S of neonatal abstinence syndrome?
General: irritable, high-pitched crying, sleep/wake disturbances, failure to thrive.
Movement: Hypertonia, hyperactive reflexes, tremors, skin excoriation.
GI: Disorganized feeding, vomiting, frequent loose stools.
Autonomic dysfuction: Sweating, sneezing, mottled skin, fever, nasal stuffiness, yawning.
The following are S/S of what condition in the newborn?
General: irritable, high-pitched crying, sleep/wake disturbances, failure to thrive.
Movement: Hypertonia, hyperactive reflexes, tremors, skin excoriation.
GI: Disorganized feeding, vomiting, frequent loose stools.
Autonomic dysfuction: Sweating, sneezing, mottled skin, fever, nasal stuffiness, yawning.
Neonatal abstinence syndrome
What is the most common illicit drug used in pregnancy?
Marijuana
Maternal marijuana use in pregnancy may impact the newborn’s:
Intelligence
Attention span
Visual memory
Executive function
May be more susceptible to depression & anxiety
Memory deficits
T/F: Mother’s who use marijuana are still encouraged to breastfeed.
False. They are discouraged from breastfeeding.
What is responsible for a significant cause of neonatal sepsis?
GBS
What has reduced rates of newborn sepsis dramatically?
Screening for GBS prenatally and giving GBS+ mothers antibiotics during labor.
What is early onset GBS in newborns?
Early onset GBS: neonatal infection from ROM (presents 24 hrs – 1 week after birth).
What are the risk factors for a newborn getting SEPSIS from a GPS infected mother?
Risk factors: preterm delivery, PROM, ROM ≥18hrs before delivery, GBS in urine during pregnancy, prior delivery of infant w/ GBS, Temp ≥100.4 during delivery, heavy maternal colonization.
The following are risk factors for what condition in a newborn?
Preterm delivery, PROM, ROM ≥18hrs before delivery, temp ≥100.4 during delivery, heavy maternal colonization.
SEPSIS from a GBS infected mother.
What are the diagnostic tests for SEPSIS in a newborn from a GBS mother?
Diagnostic tests: blood culture, lumbar puncture, CBC w/ differential & platelets, chest x-ray if respiratory symptoms present.
What is usually done to reduce transmission risk of HIV to a newborn?
C-section usually recommended at 38 weeks to reduce transmission risk
Women should continue ART therapy throughout labor & delivery.
T/: Pregnant women with HIV should discontinue ART therapy during pregnancy.
False. Women should continue ART therapy throughout labor & delivery.
What is the treatment during pregnancy for mother’s who are HIV+?
Treatment: ART during pregnancy & intrapartum, then postpartum for the infant → ART w/in 6-12 hrs after birth.
T/F: Breastfeedlng is recommended for women who are HIV+.
False. Breastfeeding is contraindicated (in high resource settings = U.S.)
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? Select all that apply.
Episiotomy
Oxytocin infusion
Forceps
Cesarean birth
Internal fetal monitoring
Episiotomy
Oxytocin infusion
Forceps
Internal fetal monitoring
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching?
“The newborn will have decreased muscle tone.”
“The newborn will have a high-pitched cry.”
“The newborn will sleep for 2-3 hours after a feeding.”
“The newborn will have mild tremors when disturbed.”
“The newborn will have a high-pitched cry.”
What is the cause of respiratory distress syndrome (RDS)?
Caused by insufficient surfactant and immature lungs.
What happens to the alveoli in respiratory distress syndrome?
The alveoli collapse with expiration leads to reduced ability to expand which leads to hypoxemia.
S/S of newborn respiratory distress syndrome
Signs and symptoms:
Low oxygen saturation (*optimal range is between 90-95% O2 sat)
Infant pale / cyanotic
Decreased lung sounds
Nasal flaring & retractions
Expiratory grunting
Use of accessory muscles of breathing
Tachypneic
Crackles if pulmonary edema present
What are the treatments/supportive techniques for newborn respiratory distress syndrome.
Treatment includes:
- Respiratory support with either CPAP or positive end expiratory pressure (PEEP) to keep alveoli open
- Surfactant therapy (usually w/in 30-60 min of birth)
Supportive care:
To decrease stress on neonate → maintain thermoregulation, provide adequate nutrition, maintain appropriate blood pressure, monitor I&O.
What condition in the neonate are the following treatments for?
- Respiratory support with either CPAP or positive end expiratory pressure (PEEP) to keep alveoli open
- Surfactant therapy (usually w/in 30-60 min of birth)
Respiratory distress syndrome
T/F: Inadequate neonatal pain management can have long-term effects on how the neonate responds to pain throughout his or her life.
True.
T/F: Pain in neonates should be treated based on how much pain the baby is in.
False. Pain should be treated preemptively when possible.