NICU

Question 1

What are the goals of developmentally sensitive care?

Answer 1

• Reduce stress and agitation
• Promote growth and healing
• Neuroprotection
• Preventing harm

Question 2

Name components of developmentally sensitive care

Answer 2

• Eyes: reduce light (dim lights, shield eyes from bright lights, eye covering with bili lights, blanket over isolette, natural light over artificial light, turn lights off when sleeping)
• Hearing: reduce noise (monitor room volume, turn down alarm volumes and silence quickly, avoid tapping on isolettes and teach families this, close portholes slowly and quietly, quiet when around open crib)
• Nose- avoid strong scents such as flowers, perfumes, alcohol swabs, etc.
• Touch: avoid sudden movements and be gentle, warm hands, keep baby well supported and contained, support head and neck, promote positive touch
• Positioning: support MSK development, arms flexed and by face, legs and hips flexed, centrally midline, use swaddling, nesting and positioning supports.
• Pain: limit painful procedures, use adequate pain relief (both pharm and non-pharm measures)
• Sleep: cluster care, watch for stress cues from baby indicating they need a break and sleep
• Skin: duoderm under bipap and cpap masks, pH neutral products, no chlorohex bath wipes, no bathing everyday, watching for skin breakdown, rotating sites where adhesive is used, moisture barrier with diaper changes, diaper change with every handling
• Temp: use warm wipes, limit time baby is uncovered, warm bankets, overbed warmer and isolette warmer when needed, socks/mittens/hat/clothing/blankets

Question 3

At what age gestation can you start using sucrose?

Answer 3

Above 27 weeks

Question 4

Characteristics of caput succedaneum?

Answer 4

• Most common, least severe
• Trauma to scalp from delivery- pressure from vaginal delivery
• Superficial hemorrhagic edema, soft and pitting over presenting part of the head
• Crosses suture lines (CS = crosses sutures)
• Max size at birth, does not grow
• Self resolving

Question 5

Characteristics of cephalohematoma?

Answer 5

• Trauma from birth- usually forceps or vacuum
• Blood collection between periosteum and skull bone (usually parietal)
• Confined by suture lines
• Causes local swelling
• Increases in size after birth, not a significant source of blood loss
• Associated with skull fracture 25% of the time

Question 6

Characteristics of a subgaleal hemorrhage?

Answer 6

• Least common, most severe
• Caused by rupture of emissary veins, may be accompanied by skull fracture
• Diffuse edema that crosses suture lines
• The subgaleal space can hold a lot of fluid so is a significant loss of blood The space expands through the entire head and down the neck.
• Early signs: diffuse swelling of the scalp, pallor, hypotonia, decreased LOC
• Progressive signs: posterior/lateral spread of swelling, pitting edema, worsening perfusion, further decrease in LOC
• Late signs: hypovolemic shock (hypotension, tachypnea, tachycardia), worsening neuro deterioration, encephalopathy, multiorgan failure, significant anemia
• Nursing interventions: monitor VS, NVS, head circumference closely after birth when vacuum or forcep assisted
• Requires fluid resuscitation and/or blood transfusion, in severe cases surgery may be necessary

Question 7

Characteristics of an epidural hematoma?

Answer 7

• Opposite of cephalohematoma- on inner side of skull between bone and periosteum
• Does not cross suture lines
• Causes increased ICP, swollen/bulging fontanelles, seizures
• Rapidly expands
• Rare, traumatic birth, linear skull fracture across middle meningeal artery

Question 8

Characteristics of subarachnoid hemorrhage?

Answer 8

• Most common
• Small and venous
• Caused by birth trauma or hypoxia
• May cause seizures or apnea
• If severe can result in hydrocephalus or neurological damage

Question 9

Characteristics of a subdural hematoma/hemorrhage?

Answer 9

• Tear in a cerebral vein or sinus, plus tear in the dura
• Secondary to birth trauma, linked to maternal use of aspirin or phenobarb
• Neurological issues at birth, further deterioration after birth
• Slowly expands and crosses suture lines
• Risk of herniation with LP

Question 10

What are the 2 phases of brain injury in HIE?

Answer 10

Phase 1- initial lack of O2 and blood flow, direct tissue injury from lack of energy and resulting acidosis from metabolite build up
Phase 2- reperfusion injury occurs 8-16 hours after oxygenation/perfusion has been restored. There is a second decrease in high phosphate energy compounds which again results acidic metabolite products building up causing more damage from inflammation and neurotoxic cytokine release.

Question 11

When must cooling be initiated by in HIE?

Answer 11

Within 6 hrs of life, but the sooner the better to prevent further complications from reperfusion injuries. Physician discretion if it is later than 6 hrs.

Question 12

Differential diagnosis for HIE

Answer 12

Exclusion of other potential neonatal encephalopathies: meningitis, encephalitis, genetic conditions, thrombophilic disorders

Question 13

Events consistent with HIE?

Answer 13

-Hypoxic event immediately before or during labour, or sudden and sustained fetal bradycardia/loss of fetal HR with decelerations.
- APGAR scores of 0-3 at 5 min of life
- Multisystem involvement
- Evidence of acute, non-focal cerebral abnormalities shown in early imaging

Question 14

Signs and symptoms of HIE (mild, moderation and severe)

Answer 14

Mild: hyperalert with normal tone and activity, exaggerated response to stim, reactive pupils, no seizure activity
Moderate: hypotonia, weak suck, constricted but reactive pupils, periodic breathing/apnea. Development of seizures or lethargy indicate deterioration
Severe: stupor or coma, absent reflexes, pupils non reactive, no spontaneous activity, requires mechanical ventilation.

Question 15

Tests done with HIE

Answer 15

• Blood gas (indicates hypoxemia or hypercarbia)
• ECG
• CSF
• CXR
• EEG
• MRI
• Blood work to assess multiorgan involvement (electrolytes, coagulation, liver function, kidney function)
• Glucose

Question 16

HIE treatment

Answer 16

• Supportive ventilation
• Maintaining a stable BP
• Temperature regulation
• Maintenance of normal glucose, calcium, and lytes
• Control of seizures

Question 17

Eligibility for cooling in HIE

Answer 17

35 weeks GA who are less than 6hrs old and meet the following criteria:
- Cord pH <7.0 or base deficit of at least -16 OR
- Cord pH 7.01-7.15 or base deficit -10 to -15.9 or no gas available AND hx of acute perinatal event AND at least 10 min PPV OR Apgar of 5 or less at 10 mins of life

AND

Evidence of moderate to severe encephalopathy as defined by clinical seizures OR the presence of at least 3 of the 6 categories.
Categories:
- LOC: lethargic (mod), stupor/coma (sev)
- Spontaneous activity: decreased (mod), none (sev)
- Posture: distal flexion, full extension (mod), decerebrate (sev)
- Tone: hypotonic (mod), flaccid (severe)
- Primitive reflexes (moro and suck): weak or incomplete (mod), absent (sev)
- Autonomic system: pupils constricted, bradycardic, periodic breathing (mod), dilated and non reactive pupils, variable HR, apnea (sev)

Question 18

How fast to rewarm a baby who was cooling?

Answer 18

0.5C per hour

Question 19

How fast do we aim to get the baby’s temp to 33.5?

Answer 19

Within 1-2hrs of admission.

Question 20

How do we monitor baby’s temp during HIE cooling?

Answer 20

Rectal probe and skin probe

Question 21

What indications would cue you to stop cooling for HIE early?

Answer 21

• Worsening or severe hypoxemia or hypotension
• Clinically significant coagulopathy despite treatment
• Arrythmia requiring medical treatment

Question 22

Can babies feed during cooling for HIE?

Answer 22

Trophic feeds can be given to hemodynamically stable babies after 24hrs. OIT can be given as soon as breastmilk is available

Question 23

When do you stop cooling for HIE if the full therapy has been completed?

Answer 23

72 hours.

Question 24

Exclusion criteria for HIE

Answer 24

• Severe IUGR (<1800g)
• Evidence of head trauma or severe intracranial bleed
• Clinically significant coagulopathy
• Palliative babies

Question 25

Expected HR during cooling for HIE?

Answer 25

80-100bpm

Question 26

What is a complication associated with rewarming for HIE? What do we do about it?

Answer 26

Seizures, may recool for another 24 hrs.

Question 27

Room setup for new admission

Answer 27

• Appropriate bed for baby
• Suction and O2 set with working MIE
• Diapers and wipes
• Cardio resp leads and SpO2 monitor with monitor setup
• Stethoscope
• IV and syringe pumps if needed
• Feeding pump if needed
• Ensure bed side cart is stocked
• Notify RT if respiratory support is anticipated so they have the machines set up

Question 28

A new admission is being ruled out for sepsis, what would you need to have setup?

Answer 28

• Covid and MRSA swab
• Urine containers and catheter ready for urinalysis and urine culture
• Supplies for bloodwork- will likely need CBC, gas, lytes, CRP, and blood culture
• Supplies for antibiotics (PIV, or PICC insertion, syringe pump, tubing)

Question 29

What factors make a neonate more susceptible to infection?

Answer 29

Maternal factors:
- GBS +
- Infectious disease during pregnancy
- Manipulative or operative delivery

Neonatal risk factors:
- Prematurity
- LBW
- Perinatal asphyxia
- Open congenital abnormailities
- Umbilical cord

NICU specific risk factors:
- Invasive procedures
- Ventilation/oxygenation
- Long length of stay
- Nosocomial infections

Risk factors for premature babies:
- Immature immune system
- Immature lungs
- Immature gut

Question 30

Clinical presentation of neonatal sepsis

Answer 30

Neurological:
- Change in LOC, decreased activity, hypotonia, seizure, jitters, sunken fontanelles
CVS:
- Poor perfusion, weak or bounding pulses, tachycardia or bradycardia, hypertension or hypotension, temperature instability, petechiae, mottling, dehydration and decreased urine output, septic shock
Resp:
- Resp distress, crackles/secretions
GI:
- Decreased PO intake, emesis, abdominal distention, loose stools
Metabolic:
- Hypo or hyperglycemia, acidosis, jaundice
Labs:
- Positive cultures, elevated or low WBCs, possible thrombocytopenia, elevated CRP

Question 31

Treatment for neonatal sepsis

Answer 31

• Fluid resuscitation for dehydration
• Optimize ventilation to account for blood gas concerns
• Treat with ABX (prophylactic until the cause is determined)
• Other symptom management
• Hypotension treatment with NS bolus, or inotrope, or epinephrine is not responding

Question 32

What does a left shift on a CBC differential indicate?

Answer 32

Left shift means that there are immature WBCs which indicates WBCs are being released from the bone marrow before they are mature due to the presence of infection.

Question 33

Strategies to prevent sepsis in newborns

Answer 33

• Treat maternal GBS before birth
• Treat any maternal infections- culture at birth and use prophylactic ABX
• Delivery within 12-14hrs of membrane rupture or there is a higher risk of infection
• Basic hygiene measures by staff (hand washing, wearing masks, hand sanitizing, etc)
• Preventing VAPs by using sterile suctioning, and performing oral hygiene
• CLABSI prevention (sterile technique with IV access, PICCs, central lines, using green caps, cap changes)
• Sterile dressing changes
• Good diaper hygiene
• Dedicated equipment kept in room, or sterilizing shared equipment

Question 34

3 anatomical differences between fetal and neonatal circulation

Answer 34

Ductus venosus: oxygenated blood from the placenta flows directly from the umbilical vein to the heart

Foramen ovale: opening between right atria and left atria. There is high pressure and resistance in the lungs from hypoxic pulmonary vasoconstriction so it is easier for the pass directly through to the left atria rather than going to through the lungs.

Ductus arteriosus: connects pulmonary artery to the descending aorta. There is high pressure and resistance in the lungs from hypoxic pulmonary vasoconstriction since the lungs are filled with fluid so it is easier for the blood the flow through the ductus arteriosus to get flow back into circulation

Question 35

Transitional period from fetal to neonate circulation

Answer 35

Ductus venosus- once the umbilical cord is clamped there is no blood flowing through so any remaining blood typically clots and the this is no longer functional.
Foramen ovale- once baby starts breathing, the hypoxic vasoconstriction releases when oxygen is sensed in the lungs, so this reduces pulmonary pressures allowing blood to flow through and return through the left atria. The pressures are now higher in the left atria than the right atria so there is a flap in the left atria that closes to seal off this opening.
Ductus arteriosus- Vasoconstricts in response to the presence of oxygen. Prostaglandin E is produced by the placenta and when it senses a lack of PgE it begins to close as well. Typically closes within 15-48hrs of life.

Question 36

Pre-op care for a baby with gastroschisis?

Answer 36

• Resp support- usually intubated (get RT)
• Maintain hydration, limit fluid loss and electrolyte loss
• Maintain perfusion of bowels (will be in sterile bag, position baby on right side to promote perfusion, ensure bowels are well supported/positioned)
• Maintain temperature (radiant warmer on)
• OG or NG for gastric decompression
• Prophylactic ABX
• Pain management
• Frequent assessments- especially vitals, airway/breathing, circulation, GI

Question 37

A new admission is coming who was born 24 weeks GA, and weighs 580g. How do you set up the room?

Answer 37

• Prepare isolette
• Set up suction, oxygen, MIE, with appropriate size masks and tubing, and prem bebonkers
• Have prem Sp02 monitor and very small BP cuff prepared. Cardiac leads will not be used due to immaturity of skin.
• Get IV pole and pumps and tubing. Prepare fluids and medication if you know what it is expected.
• Gather supplies for UVC/UVA
• MRSA swab
• ELGA box (special prem temp probe and sticker, size P3 diapers, small soothers, prem sized inline suctioning, etc.)
• Have RT made aware and set up room with vent and all associated equipment

Question 38

Preventing unplanned extubation

Answer 38

GUPPIE cards: support ETT well during suctioning; have two people for transfers, repositioning, and procedures and one of which should be an RT; RN and RT for kangaroo time, check ETT position before and after the parent hold, secure ETT and circuit while parent is holding; daily discussions during rounds

• Taping the tube and retaping as required
• Eliminate any tension on circuit
• 1:1 RN
• Assess at least hourly

Question 39

An intubated baby is in respiratory distress, what are the possibilities of what could be going on?

Answer 39

DOPE:
D- dislodgement
O- obstruction
P- pneumothorax
E- equipment

Question 40

Cause and pathophysiology of RDS

Answer 40

• Pulmonary surfactant deficiency, more common with prematurity
• Disease of immature lungs, alveoli are underdeveloped and have insufficient surface area for gas exchange. Surfactant deficiency collapses the alveoli and the infant requires more pressure to fill the lungs (surfactant breaks down the surface tension between the fluid within the alveoli allowing them to following open and expand)
• Insufficient airway pressure causes atelectasis, inflammation and pulmonary edema

Question 41

Signs and symptoms of RDS

Answer 41

Signs and symptoms present immediately after birth: resp distress, increase WOB, decreased air entry on auscultation (from atelectasis)

As atelectasis and resp failure progress: irregular breathing, apnea, cyanosis, pallor, delayed cap refill, lethargy, hypotension, cardiac failure

Question 42

Diagnosing RDS

Answer 42

• Clinical evaluation and risk factors
• ABG- resp acidosis, hypoxemia, hypercapnia
• CXR- diffuse atelectasis, visible air in bronchi, reduced lung volume

Question 43

Preventing RDS

Answer 43

• Prevent preterm labour
• Give antenatal corticosteroids 48hr before delivery to increase fetal surfactant production and speed up lung development
• Routine use of nasal CPAP after birth for early preterm babies

Question 44

Treatment for RDS

Answer 44

• Facilitate lung expansion, ventilation, and oxygenation using O2, high flow NC, CPAP, BiPAP, and mechanical ventilation as needed
• Intratracheal surfactant therapy- speeds recovery, and decreases risk of pneumothorax, emphysema, and neonatal mortality
• Inhaled nitric oxide therapy- pulmonary vasodilator, improves oxygenation by redirecting blood from diseased lung areas to more aerated, distal portions of lungs
• Monitor blood gasses
• Treat and prevent infection

Question 45

Why do you want this position?

Answer 45

• I had my consolidation placement this past fall on this unit and thoroughly enjoyed it. I enjoy the family centered care approach used in the unit and working with families during the difficult times they’re going through. I love the population, and seeing how resilient the babies are. The environment in the NICU is also something I adored and is different from any other unit I’ve worked on. It truly is a team effort, from easily being able to discuss concerns with the medical team, or pharmacy for example, and also being able to collaborate with the fellow nurses in the pod and everyone is always so helpful and offering a second set of hands to help out.
• I throughly enjoy being able to focus all my attention on one or two babies and being able to really understand everything that is going on with them. I really enjoy having the time to deep dive into the conditions present, and making connections between the lab values, understanding the plan of care, and understanding why a baby is presenting with the symptoms they have.

Question 46

What is one important thing you will bring to this position?

Answer 46

• I am a new grad nurse with little experience however I am extremely motivated to learn and expand my knowledge base. I feel I have a lot of potential in this unit to grow while doing something I thoroughly enjoy.
• I feel I have great therapeutic communication skills which is something especially important with families on this unit. I thoroughly enjoy making connections with the parents, and discussing how they’re feeling. In the NICU we are caring for the baby but also providing immense amounts of emotional supports for families.

Question 47

What is your greatest strength?

Answer 47

• My greatest strength is my ability to learn quickly and be adaptable. I am very motivated and like to go the extra mile when it comes to my learning and study outside of my placement or work to continuously try to improve. Since I am a new graduate, I realize I have a lot of learning to still be done am I will go the extra mile to make sure I am learning as much as I can. I am also very adaptable and this is important being in a new environment. I am able to catch on quickly and apply when I am taught quickly in new environments.

Question 48

What would your colleagues say are your two best qualities and provide examples of how you exemplify them.

Answer 48

I think my colleagues would say I have good attention to detail and good communication skills. I have demonstrated having good attention to detail throughout my clinical placement in the NICU by starting each shift with checking safety equipment; checking all medications, pump rates, lines, and access sites to ensure everything is correct; checking monitor settings, and more. I find keeping an organized report sheet with all tasks for the day helps me complete everything in a timely manor. I have demonstrated good communication skills through my ability to talk with parents and families using empathy and using language they understand. I have also shown my communication skills by participating in rounds and talking with physicians and other team members. I always remain professional and respectful, while advocating for the baby their needs.

Question 49

What would your colleagues say are two weaknesses of yours and why?

Answer 49

I am still new in this field so I think my colleagues would say that inexperience is one of my weaknesses at this point. This is something that all new graduates face when entering the field and I recognize I will have a lot of hard work ahead of me but it is something I am prepared to face and am willing and motivated to put the work in to improve and be the best nurse I can be. Another weakness I have is spending too long charting and writing notes. This is something I tended to fall behind on during my placement however I did continue to improve and get quicker as I became more accustomed to charting in EPIC. I think with time this is something I will continue to improve on and become more comfortable with.

Question 50

Continuing competence throughout lifelong learning is essential to the professional nursing practice; review your demonstration of commitment to continuing competence in the last 2 years. What competencies will you continue to develop/improve for your nursing practice in the future?

Answer 50

2 years ago I had just finished my first semester of nursing school so this question isn’t as applicable to me as it may be for others. But in the past two years I have worked tirelessly to gain all the knowledge, abilities, and skills that I have with me now and I am continuing to develop and learn new skills as I start my nursing career. I am working hard while I am not in the hospital setting yet to continue to grow my foundational knowledge and am also continuing my education by taking courses online such as the RNAO e-Learning breastfeeding course as this is an area I feel I lack knowledge in and would like to improve to better help mom’s I may encounter in the future should I get this position.

Question 51

Describe how you provided family centered care to the most complex family you have cared for.

Answer 51

During my placement I worked with a family who had a very complex social situation and I provided family centered care to ensure that this family had the best experience in the NICU with their baby’s care. This included letting the mom hold her baby for the first time and giving her time to take photos and hold the baby’s hand through the isolette port hole to promote bonding. I also ensured that they had the opportunity to speak with the physicians to get updates on the baby since they were unable to attend rounds. This family had social and financial concerns so getting social work involved helped this family a lot. I also provided emotional support by listening and responding with empathy and reassurance that they are doing the best they can in this situation and they are being very strong. This family had plenty of questions as well so I responded to them as best as I could, and got my preceptor or directed to the medical team when necessary. There was also a slight language barrier so whenever there were difficulties in communication I found someone who could help with translation to ensure there were no barriers.

Question 52

Explain a situation where you developed a therapeutic relationship with a family who had different values/beliefs from you?

Answer 52

• understand that preferences and beliefs may be different from our own
• leave judgements and personal biases behind / check our own judgements and personal biases
• respectfully provide education where appropriate and necessary to ensure informed consent while providing care within the nurse’s scope of practice
• try to find common ground to build the therapeutic relationship upon —> patient safety / safety of the infant, providing optimal care for the patient, actively involving the family in the care
• if difficulty arises while accommodations are being made and preferences are being respected to the best of the nurse’s ability, it may be necessary to set boundaries with the family in the best interest of the safety and care of the patient

Question 53

Situation in a critical care area that has taught me something important about myself, or left a lasting impact on me.

Answer 53

There are multiple instances in critical care where I have encountered families mourning either the loss of a loved one or their loved on is deteriorating and taking steps backward. From all of these experiences I have noticed the most difficult thing for families is losing control and wanting to do what they can to comfort their loved one. This gives me perspective when I’m working with families and serves as a reminder that although this may be everyday stuff for us, it is extremely difficult on families. I apply this by checking in wiht families to see how they’re doing and also by promoting opportunities where they can participate in care or comfort their baby.

Question 54

Recent NICU quality or safety initiatives and how you can champion them?

Answer 54

CLABSI- sterile technique when accessing, changing tubing within the appropriate time frame, always wearing gloves with central lines, cap changes, secure dressings, make sure IV lines are not hanging and touching the floor.
GUPPIE cards- ensure tubes have no tension, are secure, taped properly; use at least 2 people (1 RT) for transfers, position changes, procedures; assess hourly; 1:1 RN
Scanning breast milk
Scanning medications
ID bands attached to baby or attached to cord atatched to baby (ex. on SpO2 monitor).

Question 55

The unit implements new protocols for reducing the risk of unplanned extubation, but a coworker does not want to change their practice what would you say/do?

Answer 55

I would start off by asking them what their opinions are and why they do not want to follow this. Everyones goal is for patient safety so exploring their reasoning is important. I would explain to them my point of view and how I rationalize the change and how it reduces the risk. If this person did not agree I would suggest they discuss the change with the educators or whoever was responsible for the change for further explanations.

Question 56

What is a recent change of practice or improvement that you suggested to the team that was implemented? Was it successful? What role did you play?

Answer 56

Unfortunately I have not yet been in a position where I have been able to suggest any improvements to the team. In all of my placements so far I have been finding my footing and focusing on gaining competence and confidence. One way I will help promote improvements is by filling out a report should a mistake happen. We are all human and mistakes do happen and by reporting them it is easier for management to see common areas where mistakes are happening and make improvements so that these don’t happen in the future.

Question 57

A parent approaches you and says that they are frustrated or annoyed by the care provided by the previous nurse, what would you say/do?

Answer 57

I would explore the parent’s feelings on this and try to understand what happened that is making them feel this way. I would not comment on another nurse’s practice since I was not present and do not know the circumstances. Depending on their concerns I may be able to mitigate them by having a conversation with them, and I would discuss a plan with them so that this shift is better. If their concern is beyond being fixed with a conversation, I would refer them to the charge nurse, management, or patient experience for further investigation.