Module 2: Vinod Flashcards

Question 1

Q

Transition: Cardiovascular changes

Answer

A

Review Cardiovascular system in utero and post utero

constriction of the ductus arteriosus is a gradual process permitting bidirectional shunting of the blood
PVR may be higher than the SVR, allowing right to left shunting until SVR rises above the PVR and blood flow is directed left to right.
Most neonates have a patent ductus arteriosus in the first 8 hrs of life
spontaneous closure occurs about 42% in the 1st 24 hrs
90 % and 48 hrs-96 hours
Permanent anatomic closure of the ductus arteriosus occurs 3wks to 3 months after birth

Question 2

Q

Transition: Respiratory changes

Answer

A

at birth clamping of cord signals end of oxygenated blood flow to fetus
for respirations to be established, fetus must clear lungs of fluid, establish regular pattern of breathing and match pulmonary perfusion to ventilation
other factors: pulmonary flow, surfactant production, and respiratory musculature also influence respiratory adaptation.
Catecholamine surge experienced prior to birth helps to remove fluid from fetal lungs
infants that do not experience labor and are born via c-section are more likely to have residual fluid in the lungs and develop TTN (Transient Tachypnea of the Newborn) because of the lower levels of catecholamine.

Question 3

Q

Transition: Thermal and metabolic adaptation

Answer

A

-Newborns are predisposed to heatless because: a large surface area in relation to body weight, limited body fat, and a decreased ability to shiver. Newborns attempt to stay warm by increasing muscle activity and by burning brown fat (non-shivering thermogenesis), which increases metabolic rate. Peripheral vasoconstriction also decreases heat loss to the skin surface. The production of heat requires oxygen and glucose and produces lactic acid; therefore persistent hypothermia may result in metabolic acidosis, hypoglycemia, decreased surfactant production, and over the longer term, poor growth.19
Maternal glucose readily crosses the placenta and, under normal circumstances, supplies the fetus with enough energy to grow appropriately and to store glycogen in the liver for use after birth. The release of catecholamines occurring during labor and birth mobilizes glycogen; however, blood glucose levels decline after birth, reaching their lowest point at one hour of age.

Question 4

Q

Normal Transitional findings of the Newborn

Answer

A

-most of the transition occurs 4-6 hours after birth while cardiovascular changes may take up to 6 weeks.
During the initial hours after birth, the majority of fetal lung uid is reabsorbed, a normal functional residual capacity is estab- lished in the lungs, and the cardiovascular system redistrib- utes blood ow to the lungs and tissues. The infant moves through a fairly predictable series of events, mediated by the sympathetic nervous system, that results in changes in heart rate, respirations, gastrointestinal function, and body tem- perature. In a classic description still used today, Desmond and colleagues organized these changes into three stages:21 • The rst period of reactivity (0–30 minutes) is character-
ized by an increase in heart rate, irregular respirations, and
ne crackles in the chest with grunting and nasal aring
• A period of decreased responsiveness (30 minutes to 3 hours) with rapid shallow respirations, lower heart rate, and decreased muscle activity interspersed with jerks and
twitches and sleep
• A second period of reactivity (2–8 hours) in which exagger-
ated responsiveness, tachycardia, labile heart rate, abruptchanges in tone and color, and gagging and vomiting are commonly seen
Residual symptoms of transition such as crackles in the lungs, a soft cardiac murmur, and acrocyanosis may persist for periods up to 24 hrs in otherwise healthy infants.

Question 5

Q

Red flags in Transition

Answer

A

-Symptoms of greater than 2 hours duration
• Worsening distress
• Congenital anomalies
• Abnormal muscle tone
• Central cyanosis
• Apnea in a near-term or term infant
• Moderate-to-severe respiratory distress:
grunting
nasal flaring
marked retractions
need for supplemental oxygen beyond two hours of age

Question 6

Q

What is PPHN

Answer

A

persistent pulmonary hypertension of the newborn

PPHN is a special case of a cardiopulmonary disorder occurring in term or near-term infants that is triggered by an insult such as hypoxia, hypotension, or hypercarbia. PPHN develops when the expected drop in pulmonary vascular resistance does not occur after birth. Pressure within the pul- monary vasculature remains elevated, leading to continued shunting of blood away from the lungs and across the foramen ovale and ductus arteriosus.

Question 7

Q

Risk factors for problems in Transition: Maternal

Answer

A

Diabetes
Hypertension
Cardiac or respiratory disease
Severe anemia
Shock
Infection or febrile illness

Question 8

Q

Risk factors for problems in Transition: Antepartum

Answer

A

Intrauterine growth restriction
Placenta previa, Abruptio placenta Fetal-maternal hemorrhage
Malpresentation,
Multiple gestation
Pregnancy-induced hypertension
Illicit or prescription drug exposure

Question 9

Q

Risk factors for problems in Transition: Intrapartum

Answer

A

Chorioamnionitis
Fetal distress
Prolapsed cord
Premature or prolonged rupture of membranes Narcotic or magnesium sulfate administration Malpresentation
Shoulder dystocia
Vacuum forceps or cesarean delivery
Presence of meconium-stained amniotic fluid

Question 10

Q

Risk factors for problems in Transition: Neonatal Complications

Answer

A

Prematurity
Congenital malformations
Postmaturity
Birth trauma

Question 11

Q

TTN

Answer

A

Transient tachypnea of the newborn

Retained fetal lung fluid

due to

Late preterm infant Delivery by cesarean section, especially with no labor
Infants of diabetic mothers

Question 12

Q

Respiratory distress syndrome (RDS)

Answer

A

Surfactant deficiency and anatomic immaturity

Due to:

Prematurity

Question 13

Q

Meconium aspiration

Answer

A

Chemical pneumonitis secondary to meconium
Surfactant deactivation
Ball and valve obstruction leading to air trapping

Due to:

Term or postterm
History of meconium-stained amniotic fluid
May accompany signs of fetal intolerance of labor

Question 14

Q

Pneumonia

Answer

A

Initiation of inflammatory cascade
Secondary surfactant deficiency
Systemic illness

Due to:

Preterm
Prolonged rupture of membranes
Maternal Group B Streptococcus colonization
Maternal urinary tract infection or febrile illness

Question 15

Q

Persistent pulmonary hypertension

of the newborn (PPHN)

Answer

A

Failure of pulmonary vascular resistance to lower after birth, leading to continued right-to-left shunting, severe hypoxemia, and acidosis

Due to:

Late preterm/term infant
History of meconium aspiration, sepsis, RDS, congenital diaphragmatic hernia, and congenital heart disease

Question 16

Q

What is the PO2 of the fetus (intrauterine) compared to the newborn (extrauterine)?

Answer

A

fetus: 30
Newborn: 60-80

Question 17

Q

What is the organ of gas exchange for the fetus compared to the newborn?

Answer

A

fetus: placenta
newborn: lungs

Question 18

Q

What is the % of CO to the lungs in fetus compared to newborn?

Answer

A

fetus: 10%
newborn: 50%

Question 19

Q

What is the pulmonary vascular resistance in fetus compared to the newborn?

Answer

A

fetus: high
newborn: low

Question 20

Q

What is the systemic vascular resistance in fetus compared to newborn?

Answer

A

fetus: low
newborn: high

Question 21

Q

What is the pressure gradient in fetus compared to the newborn?

Answer

A

fetus : right > left

newborn: left > right

Question 22

Q

How is the foramen ovale presented in fetus compared to newborn?

Answer

A

fetus: patent
newborn: closed

Question 23

Q

How is the ductus arteriosus presented in fetus compared to newborn?

Answer

A

fetus: patent
newborn: closed

Question 24

Q

What is the direction of shunting in fetus compared to a newborn?

Answer

A

fetus: right to left
newborn: none or left to right

Question 25

Q

What is perinatal asphyxia?

Answer

A

Perinatal asphyxia occurs during the perinatal period. It is a life-threatening disorder that occurs when a fetus or newborn doesn’t adequately exchange gases. Asphyxia, as it is characterized by hypoxia, threatens successful transition.

Question 26

Q

What are the results of impaired gas exchange?

Answer

A

impaired gas exchange –> decreased blood oxygen levels–> increased CO2 levels –> Multisystem organ effects (MSOE)

Question 27

Q

Asphyxia can happen for a variety of reasons. About ninety percent of asphyxia occurs prenatally when gas exchange through the placenta decreases as a result of problems such as:

Answer

A

pregnancy induced hypertension (PIH)
abruptio placenta
cord compression

Question 28

Q

Fetal monitoring will often reveal an infant’s response to antenatal asphyxia:

Answer

A

fetal heart rate decelerations suggest asphyxia

- passage of meconium is also a clue to the presence of asphyxia

Question 29

Q

Post-natally gas exchange can also be interrupted and this accounts for approximately 10% of asphyxia. Some disorders that affect gas exchange in a newborn are:

Answer

A

congenital diaphragmatic hernia
sepsis
meconium aspiration
some congenital heart defects

Question 30

Q

Alteration of blood flow is an attempt to provide those organs necessary for immediate survival. Where is the blood shunted to?

Answer

A

the brain and the heart — with as much oxygen as possible. In order to do this, blood is shunted away from non-vital organs such as the lungs, intestines, kidneys, and peripheral vessels. The longer those organs receive less blood, the more damage they sustain. Unless the cause of the asphyxia is remedied, the heart and brain eventually also succumb to hypoxia and are damaged

Question 31

Q

Why is tachycardia present during times of hypoxia?

Answer

A

Reflects the heart’s effort to increase cardiac output to respond to the decrease in blood oxygen levels

Question 32

Q

How does hypoxia and asphyxia alter glucose production?

Answer

A

Hypoxia and asphyxia alter glucose production and utilization by requiring an increase in glycogeolysis to meet the increased metabolic and energy demands. Because oxygen availability is compromised, the infant switches from aerobic to anaerobic metabolism. Anaerobic metabolism is less efficient than aerobic metabolism and requires significantly more glucose to create energy. This rapidly depletes the glucose reserves; this decreased energy production is often inadequate to maintain normal cell processes and leads to the accumulation of lactic acid which causes metabolic acidosis. Hypoxia will also lead to hypercapnia (CO2) due to the body’s attempt to bring in more oxygen and will result in respiratory acidosis. Left uncorrected, these problems (hypoxia, hypercapnia, and acidosis) worsen. The result can be tissue and cell damage in all organ systems, and if enough cells in an organ are damaged organ failure will result. In addition if enough organs fail, death may ensue.

Question 33

Q

There are 4 criteria for asphyxia:

Answer

A

Arterial cord blood sample < 7
Apgar score of 0-3 for more than 5 minutes
Seizures, hypotonia, coma, or hypoxic-ischemic encephalopathy in the early postnatal period
Multiple organ dysfunction in the early postnatal period

Question 34

Q

Conditions Contributing to Asphyxia: Antepartum

Answer

A

Placental insufficiency
Maternal pulmonary disease
Maternal cardiac disease
Congenital fetal abnormalities
Prematurity

Question 35

Q

Conditions Contributing to Asphyxia: Intrapartum

Answer

A

Rotational maneuvers
birth trauma
abnormal presentation
placental abruption
prolapsed umbilical cord
maternal hypotension
infection

Question 36

Q

Conditions Contributing to Asphyxia: Postnatal

Answer

A

severe lung disease
severe apnea
congenital heart disease
persistent fetal circulation
sepsis
shock

Question 37

Q

Adjusting to extrauterine life, the newly born infant experiences a complex series of…

Answer

A

biologic, physiologic, and metabolic changes

Question 38

Q

When delivery is complicated and perinatal depression is suspected what is the aim of resuscitation?

Answer

A

to reverse

hypoxia
hypercarbia
acidosis

Question 39

Q

Resuscitation begins with…

Answer

A

thermal control
clearing of the airway if needed
stimulation of breathing

Question 40

Q

primary apnea

Answer

A

respiratory movements cease after a brief period of rapid breathing.

Question 41

Q

Asphyxia

Answer

A

Asphyxia is a process characterized by inadequate gas exchange leading to progressive hypoxia, hypercapnia, and acidosis which may occur in utero or shortly after an infant is born. Events such as pregnancy induced hypertension (PIH), abruptio placenta, cord compression, apnea at birth, or meconium aspiration can cause inadequate gas exchange. If the cause of the problem is not corrected, the infant shunts blood away from the periphery, lungs, intestines, and kidneys to try to preserve blood supply to the heart and the brain. If no intervention occurs to stop and reverse the process of increasing hypoxia, hypercapnia, and acidosis, organs become damaged (including the heart and brain), the infant stops gasping/breathing, the heart stops beating, and the infant dies.

Question 42

Q

What responses has Vinod displayed that lead you to suspect that he has been asphyxiated?

Answer

A

meconium present in amniotic fluid suggests two things: -one, that Vinod has been hypoxic in utero and two, that he is at risk for postnatal asphyxia via meconium aspiration
late heart rate decelerations during labor
need for resuscitation
spontaneous respirations not established until 2½ minutes of age
color didn’t improve until 2½ minutes of age
not moving arms and legs until 2½ minutes of age
low Apgar score — especially at one minute
still pale after resuscitation

Question 43

Q

Identify at least one negative response in each of the following systems that could occur as result of Vinod having been asphyxiated.

pulmonary system

Answer

A

respiratory distress, meconium aspiration, persistent pulmonary hypertension, atelectasis, and pneumonia

Question 44

Q

cardiovascular system

Answer

A

congestive heart failure, cardiogenic shock, hypotension, and disseminated intravascular coagulation (DIC)

Question 45

Q

gastrointestinal system

Answer

A

feeding intolerance and necrotizing enterocolitis (NEC)

Question 46

Q

renal system

Answer

A

decreased urine output, hyperkalemia, and renal failure

Question 47

Q

central nervous system

Answer

A

hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia PVL, seizures, and sometimes long-term neurological problems such as spasticity, ataxia, and cognitive deficits

Question 48

Q

What nursing measures could you implement in order to prevent further asphyxia and to prevent the complications associated with asphyxia?

Answer

A

Some of the nursing measures you could implement to prevent further asphyxia and prevent complications associated with asphyxia include:

immediate effective resuscitation with provision of warmth, ventilatory support, and maintenance of adequate circulation. Establishing spontaneous respirations, a normal heart rate, and correcting acidosis will prevent further brain injury
assess for the effects of asphyxia — hypoxia, hypercarbia, acidosis, and hypoglycemia which may show up in many ways — seizures, apnea, respiratory distress, intolerance of feeds (when started), and temperature instability
closely monitor the infant’s vital signs (including blood pressure), oxygen saturation, blood work results, and urine output

-maintain the infant’s warmth — prevent cold stress
ensure sufficient glucose intake — usually the infant is NPO, so an IV is initiated. Fluid intake may be restricted to 50–70 ml/kg/hr to prevent fluid overload (since renal function may be impaired due to hypoxia) and to prevent cerebral edema

keeping the infant NPO will give the gut an opportunity to recover
apply ACoRN framework to evaluate and/or guide the care the team is providing

Question 49

Q

Meconium aspiration

Answer

A

Meconium aspiration is a common feature of perinatal asphyxia for full- and post-term infants. Preterm infants, particularly those less than 32 weeks gestation, rarely experience meconium aspiration as their gut contain very little meconium. Full- and post-term infants, in contrast, have large amounts of meconium in their colons.

When full- and post-term fetuses experience hypoxia, their gastrointestinal wall relaxes and meconium is expelled into the amniotic fluid. The hypoxia will cause the fetus to gasp. When the fetus is delivered, aspiration of the meconium occurs during the first breath, severe respiratory distress can result from the meconium blocking small airways, trapping air, and initiating an inflammatory response.

Question 50

Q

Post-term infants are at particular risk for meconium aspiration for several reasons:

Answer

A

they have large amounts of meconium in their gut
these infants can be quite large (if they continue to grow in utero) and consequently suffer second stage problems arising from their larger size
if they have not been growing — because the placenta has been deteriorating — they will likely be stressed and may already be experiencing hypoxia, causing meconium passage

Question 51

Q

Meconium aspiration causes hypoxia in the neonate by:

Answer

A

airway obstruction
-physically obstructing the glottis, trachea, and smaller airways resulting in atelectasis, air trapping and alveolar collapse

surfactant dysfunction
-meconium deactivates surfactant and may inhibit surfactant synthesis

chemical pneumonitis
-an inflammatory response to meconium in the airways and parenchyma

increased pulmonary vascular resistance
-which results in the ductus arteriousus staying open (right to left shunting) and the maintenance of fetal circulation

Question 52

Q

The following diagrams compare normal and impaired pulmonary blood flow.

Answer

A

In the presence of hypoxia, pulmonary vasoconstriction continues, which in turn will maintain a patent ductus arteriosus leading to pulmonary hypoperfusion. This will continue the cycle of hypoxia and PPHN, a cycle that is difficult to break.

It is extremely difficult to treat this cycle and infants with PPHN can experience profound ongoing hypoxia that can lead to significant multi-system organ damage. In addition to the added multi-system effects of asphyxia infants like Vinod can result in increased illness. (see diagram)

Question 53

Q

Persistent Pulmonary Hypertension of the Newborn

Answer

A

Full- and post-term infants are particularly vulnerable to PPHN because the muscles in the walls of their pulmonary vessels are well developed and are highly sensitive to hypoxia. Preterm infants, while they can and do experience asphyxia, are less likely to develop PPHN as their pulmonary vessels are less muscularized and less sensitive to hypoxia. The development of PPHN significantly adds to an infant’s vulnerability, morbidity, and mortality.

Very briefly, this is why: a rising blood oxygen level is critical to successful transition. Recall that in utero, low pO2 levels help to keep the ductus arteriosus open and cause pulmonary vasoconstriction. Together, a patent ductus arteriosus and pulmonary vasoconstriction shunt blood away from the lungs (right-to-left shunting). During transition, a rising pO2 begins to close the duct and causes pulmonary vasodilation, lung fluid is absorbed and the lungs take over the process of gas exchange (which was previously done by the placenta).

Question 54

Q

NRP incorporates the ABC’s of resuscitation:

Answer

A

airway – position and clear
breathing – stimulate to breath
circulation – assess heart rate and color

Most newborns will require only the initial steps in resuscitation (stimulating and assessment); however, a very small number will require increased resuscitation efforts (chest compressions and medications).

Question 55

Q

Practice apgar

Answer

A

heart rate, resp effort, muscle tone, irritability and color.

Question 56

Q

Management of perinatal asphyxia involves every organ system. Why is that so?

Answer

A

Management of perinatal asphyxia involves every organ system because perinatal asphyxia has multiple organ system sequelae. Every organ system is vulnerable as a result of perinatal asphyxia and must, therefore, be supported.

Question 57

Q

How, in general, would you approach assessment for Vinod?

Answer

A

Assessment during resuscitation is based on the NRP sequences of: airway, breathing, and circulation. In these sequences position, color, HR, respiratory rate, and effort are important parameters.

Assessment must also be multi system. Once an infant is resuscitated and stabilized, a baseline assessment must be done with a view to collecting key information in each system. This can be done by a systems approach or from a head to toe approach. Whichever approach you chose, ensure that you are always doing a thorough assessment of the infant and family.

Question 58

Q

Blood Gas Analysis

Answer

A

Blood gas analysis assesses three interrelated, but separate processes: oxygenation, ventilation, and acid-base homeostasis.
normal blood gas values:
pH: 7.35-7.45
pCO2: 35-45
PaO2:50-80
P02 (cap): 40-60
HCO3-:20-26
BE: -4 - +4

Question 59

Q

Oxygenation

Answer

A

Oxygenation is assessed by how much oxygen the lungs are delivering to the bloodstream, told by the pO2 and oxygen saturation.

pO2 measures dissolved oxygen (3% of total oxygen)
normal values for pO2 are: arterial sample = 50–80 mmHg, capillary sample = 40–60 mmHg
Arterial pO2 values are much more accurate than capillary pO2 values

O2 sat measures oxygen carried on hemoglobin (97% of total oxygen)
normal range for O2 saturation is 88–95%
pulse oximetry should be used instead of capillary pO2 values (as they are not as accurate as arterial values)

Question 60

Q

Ventilation

Answer

A

Alveolar ventilation is determined by the pCO2 level. Carbon dioxide is very sensitive to minute ventilation, which is the volume of air inspired and exhaled in a minute. Minute ventilation (tidal volume x rate), and in particular, tidal volume (volume of air moved with each breath) is affected by the functioning of the pulmonary system.

-normal values for pCO2 are 35–45 mmHg

-hypoventilation leads to a buildup of CO2
A high amount of CO2 in the bloodstream, such as when ventilation is impaired, decreases the pH as excess carbon dioxide combines with water to form carbonic acid, creating respiratory acidosis

-hyperventilation leads to a decrease in CO2
A low amount of CO2 in the bloodstream, usually caused by over ventilation, will cause a respiratory alkalosis

Question 61

Q

Acid-Base Homeostasis

Answer

A

Acid-base homeostasis is the balance of acid to base necessary to keep the blood pH level normal.

Question 62

Q

Respiratory acidosis

Answer

A

caused by too much CO2, which combines with water to form carbonic acid, which in turn drops the pH
commonly caused by hypoventilation

Question 63

Q

Metabolic acidosis

Answer

A

caused by too much lactic acid
occurs with hypoxia and/or poor perfusion
anaerobic metabolism produces a lot of lactic acid as a byproduct, which lowers the pH
caused by failure of the kidneys to eliminate the hydrogen ions they normally eliminate from the body via urine
caused by failure of the kidneys to reabsorb the bicarbonate they normally recycle back into the body

Question 64

Q

Respiratory alkalosis

Answer

A

alkalosis (state of too much base or too little acid) is caused by too little carbon dioxide
occurs with hyperventilation

Answer 65

A

caused by loss of acid through gastric suctioning

Alkalosis is a far less common neonatal response to illness than is acidosis. Both respiratory and metabolic acidosis are common neonatal blood gas abnormalities.

Occasionally, respiratory alkalosis is seen in an infant who is hyperventilating, either spontaneously or by a mechanical ventilator set with too high of a rate.

Metabolic alkalosis will rarely be seen.

Answer 66

A

This pH is decreased, indicating acidosis. It is actually quite low. When a pH is this low, it suggests that the acid-base imbalance might be a mixed problem: that is, both metabolic and respiratory in origin.

Answer 67

A

pCO2: 61 , bicarb: 17, base excess: -5
The high pCO2 suggests respiratory acidosis.
The low bicarb and low base excess suggest metabolic acidosis.
Therefore, this is a mixed — respiratory and metabolic — acidosis.

Answer 68

A

pO2: 35
This pO2 is low for a capillary sample. When assessing pO2, it is important to know whether the sample
is arterial or capillary. If capillary, it is not useful. Pulse oximetry is better.

Answer 69

A

pCO2 61
This indicates hypoventilation, usually the result of lung disease. In Vinod’s case, I would suggest the meconium aspiration and resultant air trapping are to blame for the hypoventilation and elevated pCO2.

Answer 70

A

Vinod’s blood gases reflect his asphyxia and his failure to adequately exchange gases. The high CO2 leads to respiratory acidosis. The low O2 leads to anaerobic metabolism, production of lactic acid, and a metabolic acidosis. This is a typical picture of asphyxia: hypoxia, hypercapnia, and mixed acidosis.

Answer 71

A

Sharon should inform Debra. She should give oxygen to keep oxygen saturation above 88% and repeat a blood gas in two hours. If Vinod is not already intubated and ventilated, it may be necessary to intubate and ventilate him. Mechanical ventilation will blow off Vinod’s CO2 by increasing his minute ventilation.

Answer 72

A

time of onset and duration of seizure
preceding activity, e.g., at the end of a feed
type of movement, e.g., cycling, twitching
body parts involved, e.g., right arm
change in level of consciousness/alertness
change in vital signs
post seizure status — alertness, vital signs, tone

Answer 73

A

intracranial hemorrhage (IVH) is responsible for up to 16% of seizures in infants. Intraventricular hemorrhage is also often caused by asphyxia and/or hypoxia and is common in preterm infants
metabolic disturbances — hypoglycemia, hypocalcemia, hypomagnesemia, and hyperphosphatemia
bacterial meningitis (often group B Strep)
viral encephalitis
the most common cause of seizures in term infants is hypoxic-ischemic encephalopathy (HIE), accounting for 60–65% of seizures. Hypoxicischemic encephalopathy is often caused by asphyxia and is characterized by decreased blood flow to the brain, resulting in areas of ischemic damage.

Answer 74

A

stay with the infant and observe him/her closely
if the infant is apneic or shows signs of respiratory distress, provide oxygen and ventilation as necessary
attempt to stop the movement by gently touching or flexing the involved extremity — this will distinguish seizures from jitteriness
document the seizure noting: preceding events or disturbances, exact description and type of seizure activity, duration of seizure, and condition of infant during and following the seizure
report the seizure activity, specifying why you felt this was a seizure and not a normal movement or jitteriness
review results of diagnostic tests to determine the cause of seizures
give medications as ordered to control the seizures
ensure the parents are informed of the seizure and provide support to them
support and comfort the infant during and after the seizure

Answer 75

A

Hypoxic-ischemic encephalopathy (HIE) is a neurologic condition often experienced by full- and post-term infants who have been asphyxiated. The hypoxia associated with the asphyxia leads initially to increased cerebral blood flow. Over time, as hypoxia worsens and acidosis develops, cardiac performance is decreased, and cerebral blood flow decreases. Diminished perfusion with hypoxemic blood causes damage to vulnerable brain cells. In term and post-term infants, the most vulnerable area of the brain is the cerebral cortex. The extent of damage caused by HIE is best diagnosed by MRI, 48 to 72 hours after the insult. Long-term neurologic outcome can range from mild to severe.

Note: When the hypoxia associated with asphyxia leads to increased cerebral blood flow, this is the time that a preterm infant can experience an intraventricular hemorrhage.

Answer 76

A

3,850 gm = 3.85 kg

3.85 kg ´ 10–20 mg/kg = 38.5–77 mg

Answer 77

A

The most common side effect of phenobarbital seen in neonates is respiratory depression. Therefore, close monitoring and availability of oxygen and bag and mask ventilation equipment are important.

Answer 78

A

His blood glucose was normal, suggesting hypoglycemia is not to blame, but perhaps this should be rechecked.
Metabolic disturbances probably aren’t the cause of Vinod’s seizures — but, to rule this out, we need to know the calcium, potassium, and magnesium levels.
Sepsis may be a possibility; we don’t have enough information to determine this. The preliminary blood culture results won’t be available until 48 hours after collection. We do know that Ranjeet’s membranes ruptured within 18 hours of delivery, which does not present a high possibility of sepsis due to prolonged rupture of membranes. We do not know if Ranjeet’s cervix was swabbed for group B Strep (a frequent cause of sepsis in newborn infants). We do know that, so far, Vinod’s temperature has been within normal limits and there has been no sign of apnea or bradycardic episodes (these are frequent signs of sepsis). His WBCs were normal from the preliminary blood work.
Given the information provided, the most likely cause of Vinod’s seizure is hypoxic ischemic encephalopathy secondary to asphyxia.

Answer 79

A

This question could be answered in a variety of ways. Some things to think about are:

language — are the words you use easily understood by non-health professionals?
tone — are you conveying concern, panic, reassurance?
pacing — is there ample opportunity for parents to ask questions?
amount — how much information is too much? too little?

Answer 80

A

Anxious, fearful, confused, panic, bewilderment, overwhelmed, sad, guilty … there is a wide range of emotional responses that parents display when their newborn is ill. We can only speculate. If you were actually caring for this family it would be important to try to find out from them how they are feeling, what they are concerned about, and what they need.

Answer 81

A

provide the parents with emotional support and factual information about what is happening with Vinod. Keep in mind you may need to repeat the information several times
offer to contact family members/friends who can provide support for the parents
provide Ranjeet and Jason with information about where Vinod is going: the specific address of the hospital, the phone number of the NICU he is being transferred to, directions as to how to get to the new hospital, any information about the unit (e.g., give them an information brochure/pamphlet about the unit if available)
talk with Ranjeet’s postpartum nurse and discuss the feasibility and appropriateness of obtaining a discharge order for Ranjeet so she can accompany Vinod to the tertiary center
discuss with the physician in charge of transferring Vinod or the infant transport team the possibility of Ranjeet accompanying Vinod in the ambulance

-encourage Ranjeet and Jason to touch/stroke/talk to Vinod, and possibly hold him while awaiting transfer
acknowledge any feelings of fear, anxiety, grief, etc. expressed by Ranjeet and Jason, and encourage them to express their feelings if they want. Validate that their feelings are normal

provide a private place in NICU (through the use of screens, curtains, etc.) where Vinod and his parents can be without the curious eyes of other parents, etc. observing their every move during this stressful time
provide Ranjeet and Jason with a photograph of Vinod (many units have a camera available for just this purpose)
discuss with Ranjeet her plans for feeding Vinod — i.e., is she planning to breast-feed Vinod. Hopefully Sharon or her postpartum nurse has already talked with her about this and if she is planning to breast-feed, she is starting to express her milk (pump)

Answer 82

A

Some of the factors that remove control from parents who have babies admitted to NICU include:

the environment of a typical NICU — the equipment, the noise, the number of people
the lack of a normal typical routine that occurs with a newborn who doesn’t have any special needs — infants usually are in the room with their mothers, the main focus is on how to care and feed the infant, there is lots of happiness, etc. In contrast, holding, caring for, and feeding the infant in NICU is often limited.
fear of death and disability of the infant — the loss of the perfect infant
lack of knowledge about what is happening to their infant

Answer 83

A

find out what they need
provide factual, honest information
encourage contact with the infant — talking, touching, and holding if possible
involve parents in decision making — e.g., treatment decisions, feeding times, etc.
involve the parents in the infant’s care — dressing or providing clothing for the infant, changing the infant’s diaper, taking the infant’s temperature, etc. — as soon as it is medically safe and reasonable
encourage the parents to spend as much time as possible with their infant
encourage parents to ask questions

Answer 84

A

uses copious amounts of glucose to create energy
Is less efficient than aerobic metabolism
leads to lactic acid production

Answer 85

A

measuring pO2 in the blood and pulse ox

Answer 86

A

obstructing the airway
chemical pneumonitis
increasing pulmonary vascular resistance
deactivating surfactant

Answer 87

A

they are having jitteriness

Answer 88

A

collapsed and fluid filled

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Module 2: Vinod Flashcards

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