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Low risk neonate test

Terms in this set (180)

sodium bicarbonate should not be given unless...
-serum bicarbonate level <15-16mEq/L
-PaCo2 level <40-45mmHg
-adequate spontaneous or assisted ventilation
-cause of acidosis is being assessed & treated
signs of respiratory distress
-tachypnea, retractions, flaring or grunting persist beyond 1 hour after birth
-any time severe or worsening tachypnea, retractions, flaring, or grunting develop
-any time cyanosis or low SpO2 is present
what part of the baby's body should you examine to determine if the baby is cyanotic
lips
a baby, 30 mins after birth is pink but shows mild grunting & nasal flaring. you check the baby vital signs & they are normal. what would you do next?
attach a pulse ox and observe the baby
at 3 hours after birth, a 1,900g (4#3) baby develops mild grunting, intercostal retractions, and nasal flaring, and RR 80bpm, but is pink all over. it is 0400. what should you do?
-take the baby's V/s
-attach a cardiac monitor
-attach a pulse ox
Respiratory distress syndrome (RDS) is caused by
lack of lung surfactants
many times, correction of underlying non-pulmonary problems can significantly diminish or completely eliminate a baby's respiratory distress
...
baby usually breathe through their noses. they usually cannot breathe through their mouths
true
what causes respiratory distress syndrome?
immaturity of the baby's lungs & the resulting lack of surfactants needed to keep the alveoli open
what causes respiratory distress?
-blockage in airway between the nose & lungs
-immaturity of baby lungs & resulting lack of surfactants needed to keep alveoli open
-inhalation of amniotic fluid into the lungs
-low blood volume
-thick blood
list 2 obstructive causes of respiratory distress
-mucus
-mechanical obstruction (i.e. misplaced phototherapy mask)
-choanal atresia
-pneumothorax
-diaphragmatic hernia
-robin syndrome
list 2 primary lung problems that causes respiratory distress
-aspiration syndrome
-pneumonia
-transient respiratory distress
-hypoplastic lungs
list 3 non-pulmonary problems that may cause respiratory distress
-preterm babies
-babies with difficult deliveries
-babies born to women with diabetes
-babies born by c-section
list 3 groups of babies who are at risk for developing respiratory distress
-preterm babies
-babies with difficult deliveries
-babies born to women with diabtes
-babies born via c-section
-babies born to women with fever, prolonged ROM, foul-smelling amniotic fluid, and/or risk factors for GBS+
-meconium stained babies
-babies born to women with polyhydramnios
-babies experiencing cold stress, hypotension, anemia, polycythemia
what should be done for a baby showing signs of respiratory distress?
-monitor pulse ox
-obtain: ABGs, CXR, Hematocrit, CBG, WBC with diff.
-consider BC and abx
if grunting is the primary physical symptom, you would suspect the baby has _________ lungs. you would obtain a _______ to help elevate the cause.
-stiff
-CXR
if a catheter cannot be passed through the nose of a baby with respiratory distress, you would suspect the baby has ______. you would immediately insert _____ in the baby's mouth.
-choanal atresia
-oral airway
if a baby with respiratory distress suddenly turns blue, you would suspect the baby has ______. you would perform a ______ & obtain ______ to confirm the dx.
-pneumo
-transillumination
-cxr
if a baby in respiratory distress soon after birth has a hematocrit of 30%, the baby probably experienced _______. you should prepare to give ______.
-perinatal blood loss
-blood transfusion
if arterial PaO2 is low, increase the baby's _______to avoid damage to the babys brain.
inspired oxygen concentration
if arterial PaO2 is very high you should _____ the amount of inspired oxygen to avoid damage to the eyes and lungs
decrease
if arterial PaCO2 is high and pH is low, you should
ventilate the baby
if arterial PaCO2 is normal and pH is low, you should consider
giving sodium bicarbonate
when breathing stops for longer than 20 seconds or for a shorter period if accompanied by cyanosis or bradycardia
apnea
problems that put a baby at risk for apnea
-preterm
-rapidly worsening resp. distress
-metabolic d/o (i.e low blood glucose, calcium, sodium, acidosis)
-sepsis or meningitis
-rewarming of a cold-stressed baby
-over-warming
-CNS d/o
-low blood volume or hematocrit
-hx of severe hypoxia and/or acidosis
-maternal depressant drugs during labor
all babies at risk for apnea should be monitor how?
-heart rate and resp. monitor, and pulse ox
screening procedures for a baby who has experienced apnea
-ABG
-CXR
-CBG
-BP
-babys temp, environ. temp, oxygen/air temp if being used
-hematocrit
-evaluate for sepsis and meningitis
-evaluate for seizures, assess neuro status
-serum sodium, calcium, & pH
-evaluate feedings for possible milk aspiration
when can apnea monitoring be discontinued
-acute illness has resolved
-baby weighs >1,800g and >35 wks
-apnea free for 7-8 consecutive days
collection of air within the chest cavity, between the lung and the chest wall that results from a rupture in the lung tissue, allowing air to leak outside the lung
pneumothorax
which babies are at higher risk for pneumothorax
-PPV
-poor lung compliance (stiff lungs), as seen with RDS
-aspiration syndrome
-babies requiring resuscitation
signs of a pneumo
-sudden onset of cyanosis or decreased SpO2
-increase or decrease in respiratory effort or rate
-breath sounds louder over one lung
-shift in location of heart sounds
-unequal chest expansion
-abdominal distention
-low BP, esp. when it has been normal
-deterioration in appearance with poor peripheral perfusion
when a baby has a pneumonia, you would expect the PaO2 concentration to _____, PaCO2 to _____, and blood pH to ______.
-decrease
-increase
-decrease
2 techniques to tx pneumo
-chest tube
-needle aspiration
place baby with pneuma in what position
lateral decubitus position (with side under suspicion up)
if a baby needed emergency medications, you would give through
UVC
obtain blood samples for monitoring blood oxygen, carbon dioxide, and pH from
UAC
what are the possible dangers with a UVC
thrombosis and blood infection
you are inserting an UAC. the baby's toes on his R foot suddenly turn white. what should be done?
remove the catheter
3 blood vessels of an umbilical cord
2 arteries and 1 vein
uses of UVC
-emergency meds
-exchange transfusions
-emergency estimation of PCO2 and pH (not pO2)
-fluid administration during the first few days in extremely preterm babies
uses that are NOT recommended for UAC
-exchange transfusion
-emergency meds
most common use of UAC
drawing blood for ABG tests
rate to give infusions and flush solutions through UVC or UAC
slowly and steadily. no faster than 1-2 ml/kg/min
blood pressure occurs as a result of
-pumping action of the heart
-volume of blood
-tone of the blood vessels
a palpation BP most closely approximates the....
diastolic BP
recommended initial dosage of fluids to increase the blood volume of a 2,000g (4#6.5) baby who is in shock?
20ml
best estimate of the total blood volume of a 2000g baby?
(2kgx90ml/kg)
180ml (6oz)
what min amount of blood loss would put a 2,000g baby into shock? (180ml x25%)
45ml (1.5oz)
which fluid is best to use to restore a baby's blood volume
NS
what can happen to babies with low BP
-acidosis
-vital organs can be damaged
-rapid respirations can develop
low BP in newborns is associated with
-poor oxygenation
-polycythemia
-CNS insult
recommended methods to take BP
oscillometric and palpation
if a fetus-to-fetus transfusion develops in utero, it can cause______in the donor fetus and ________ in the recipient fetus
-anemia
-polycythemia
normal BP of a newborn
90ml/kg or 40ml/lb
recommended fluid for volume expander
NS
recommended starting amount for volume expander
10ml/kg
recommended rate of admin of volume expander
over 5-10 min
how is low blood volume treated
volume expander
BP measurement shows a baby in shock. blood loss is suspected. what should be done?
give NS immediately
possible causes of hypotension
-low blood volume or blood loss
-poor oxygenation
-severe acidosis
-severe CNS insult
-poor cardiac output
-sepsis
situation where a baby is most likely to develop feeding problems
-excess amniotic fluid
-3 day old, term baby who has not stooled
important characteristic of formula for preterm babies
osmolarity same as breast milk
2 hour old AGA has rapid, shallow respirations at 80bpm requiring 30% oxygen. how would you provide fluids/nutrition?
-peripheral IV fluids
which baby requires tube feeding instead of nipple feedings
30 week AGA with a strong suck reflex
what procedure should be carried out before each tube feeding
aspirate the stomach contents, record the amount, and refeed the fluid to the baby through the tube
a women with hydramnios delivered a full term, vigorous baby. at 30 mins of age, the baby is noted to have excessive mucus. what would you do before the first feeding?
insert an OG or NG tube and elevate for obstruction before feeding
which of the following in an otherwise healthy baby would be of the most immediate concern to you?
bilirubin level of 9 at 10 hours of age in a full-term baby
which baby would you expect the binding capacity of serum protein for bilirubin to be least affected?
a baby with htn
when a baby is jaundiced, what is the first action you should take?
obtain blood samples for lab testing
jaundice appearing within 24 hours of birth is usually
abnormal
newborns are more likely than adults to have hyperbilirubinemia because
-decreased removal of bilirubin by the liver
-increased production of bilirubin due to breakdown of more RBCs at a faster rate
-increased reabsorption of bilirubin from intestines
bilirubin of babies with very low apgar scores may be dangerous at _______ bill level than for a baby with high apgar scores.
lower
routine testing for hyperbilirubinemia
-coombs test
-hematocrit
-blood smear
-mothers and babys blood group
when treating a baby girl with phototherapy lights you would
completely undress the baby
what problem can result from hyperbilirubinemia
brain damage
what does the binding capacity of serum protein mean
it is the capacity of serum protein to attract and hold bilirubin
cut off for TC bill reability
12mg/dl
-TC bill should not be used with phototherapy
when is bilirubin dangerous to the brain
when it leaves the blood and enter the brain
which conditions make a given level of hyperbole. more dangerous
-prematurity
-sepsis
-perinatal compromise
-acidosis
-illness (lethargy, temp instability)
-low serum albumin (<3.0g/dl)
-certain meds
in general, jaundice should NOT be considered physiologic if
-appears in the first 24 hours
-bili levels rise faster than 0.5mg/dL per hr
-there is evidence of hemolysis
-physical exam is abnormal
-direct serum bili exceeds 20% of total bili
-jaundice persists for more than 3 weeks
a 1,900g baby of 33 weeks with resp. distress and bill level of 10 at 36 hours
begin phototherapy
3,000g term baby with hemolytic disease from ABO incompatibility & a bili level of 20 at 36 hours while under going intensive phototherapy since 8 hours of age. what would you do next?
exchange transfusion
a formula fed baby at 40 weeks with no complications has a serum bili of 15 at 36 hours. what would you do to treat?
begin intensive phototherapy
36 weeks with serum bili of 8 at 30 hours.
consider phototherapy
39 weeks get. with 1 min apgar of 2 who required prolonged resuscitation, became jaundiced by 12 hours and has a serum bili of 10.
begin intensive phototherapy
common problems that can develop as a result of phototherapy
-eye damage (if not covered)
-rash
-nasal obstruction (from slipped eye patch)
-increase in stools
-increase in evaporative water loss
-hyperthermia
what is the most common clinical sign indicating a newborn has a systemic infection
low body temp
an infected baby may develop ______acidosis
metabolic
what is the first thing that should be done for a baby suspected of having a systemic infection?
obtain BC
which procedure is most effective in controlling the spread of infection in the nursery?
required hand washing between handling babies
what is the one reason babies become infected more often than adults
their immune system is immature
-they have not built up antibodies against specific organisms
-if preterm, their maternally acquired antibody levels will be low
babies with mild staph infections only require
mild soap and water washes to the affected area and application of abx ointment
congenital syphilis should be treated with
10-14 days of IV abx
localized infection of the eyes that requires systemic abx treatment
gonococcal conjunctivitis
which conditions place a baby at risk for developing a systemic infection
-ROM >18hours
-labor >20 hours
-maternal fever (38C/100.4F) during labor
-preterm delivery
-genital herpes simplex lesions at the time of ROM
-GBS + or hx of previous baby with GBS infection
-invasive procedure (umbilical catheter)
-prolonged hospitalization (several days)
risk for developing localized infections
-high staph rates in other newborns in nursery
-any puncture sites (even heel sticks and scalp electrodes)
-staph, GC, or chlamydia infections predisposing baby to conjunctivitis (eye infection)
congenital intrauterine infections
-mother contracts rubella during preg
-syphilis
-cat litter exposure
-active genital herpes
-cytomegalovirus
-varicella
-Hep B +
-HIV +
s/s systemic infection
-resp difficulty (grunting, nasal flaring, retracting, tachypnea, or apnea spell)
-marked increase or decrease in HR
-unexplained hypotension
-reduced body temp (elevated is less common)
-pale, gray, or mottled color, poor cap refill
-poor feeding
-change in activity (lethargy or decreased tone, or irritability)
-abdominal distension, vomiting, jaundice
-seizure activity
Cytomegalovirus clinical findings
-IUGR
-jaundice
-thrombocytopenia
-purpura
-blueberry muffin spots
-hepatosplenomegaly
-microcephaly
-cerebral calcifications
-chorioretinitis
-cataracts
diagnosis for CMV
-viral culture of urine or salvia
tx of gram positive bacteria
ampicillin
tx of gram negative bacteria
gentamicin
early markers for infection
CRP >7.5 or procalcitonin >2.5
clinical findings of congenital syphilis
-unexplained jaundice
-rash
-hepatosplenomegaly
-pneumonia
-anemia
-lymphadenopathy
-thrombocytopenia
**however most infected babies will not have any of these findings
dx of congenital syphilis
nontreponemal (VDRL, rapid plasma reagin, & automated reagin test) serologic test of baby blood (not cord blood) -
lumbar puncture and treponema (microhemagglutination assay)
x rays of long bones
other tests include CXR, CBC, liver function tests, ophthalmologic exams, auditory brain stem response test
at what age can infants born to HIV + mothers be diagnosised
4-6 months
neonatal s/s of toxoplasmosis
-hepatosplenomegaly
-jaundice
-thrombocytopenia
-anemia
-seizure
-microcephaly
-hydrocephalus
-intracranial calcifications
-lymphadenopathy
best way to measure concentration of arterial oxygen
ABG sample
a baby with respiratory distress is breathing 45% oxygen and hs an arterial blood oxygen tension of 96mmHg. what adjustments in oxygen should be made for this baby?
change inspired oxygen to 40%
a baby's eyes may be damaged from periods of too much
oxygen in the blood
what is the best way to gauge the amount of oxygen a baby needs?
ABG measurement
best way to regulate the amount of oxygen a baby needs
use of an oxygen blender
normal arterial blood oxygen level (PaO2)
45-65 mm Hg
pulse oximeters measure the amount of oxygen
bound to hemoglobin
normal arterial pH
7.27
normal arterial PaCO2
40-50mm Hg
normal umbilical vein pH
7.34
normal capillary pCO2
45-55
normal umbilical vein pCO2
40
normal pCO2 of umbilical arterty
50
what may happen when a baby who requires additional oxygen is removed from oxygen for a brief period
if lowered too rapidly, the parties in the lungs may constrict, reducing oxygen flow to the body, resulting in low arterial blood oxygen level. causing baby to become sicker
a baby's Spo2 is 90% while he is breathing 45% oxygen. the concentration of inspired oxygen should be
not to be changed at this time
2 organs most likely to be damaged from too little blood oxygen
brain and kidneys
organ most likely to be damaged from too much blood oxygen
eyes
organ most likely to be damaged from supplemental inspired oxygen over a long period
lungs
a baby has a oxyhemoglobin saturation of 84% in an inspired concentration of 37%. what should you do?
-increase the inspired oxygen concentration until the oxyhemoglobin saturation is between 85-95%
-check if the oximeter is working properly
a baby is in an FiO2 of 50%, has a PaO2 of 35mmHg and Spo2 of 80%. how should you adjust the babys inspired oxygen concentration?
increase it
baby's attempt to produce PEEP
grunting
flow of heat from the body to cooler surrounding air
convention
how to prevent heat loss by convention
eliminate drafts
transfer of body heat to a cooler solid object in contact with baby
conduction
how to prevent heat loss by conduction
warmed blankets
heat loss from heat radiating towards a cooler surface
radiation
example of heat loss by radiation
cold window, wall , or incubator wall
heat loss through wet skin after birth
evaporation
"stays where i put it"
isotonic-NS, d5w, LR
posterior fontanel closes by
2-3 months
very large anterior fontanel
hypothryoidism
evidence of bruit over fontanel with suspected cardiac failure is associated with
intracranial arteriovenous malformation, which may be the cause of CHF
tan or light brown oval shaped macule with well defined border
cafe au lait patch
autosomal dominant d/o in which tumors of various sizes form on peripheral or cranial nerves (90% have cafe au lait spots)
neurofibromatosis (Von Recklinghausen disease)
dark brown or black macule caused by proliferation of melanocytes within epithelial structures that sometimes extend into the subs. fat. commonly seen on lower back or buttock
congenital melanocytic nevus (pigmented nevus)
late sign of dehydration
poor skin turgor
when infant is lying on one side a sharply demarcated red color is seen in dependent half of the body with superior half appearing pale. if infant rotated to the other side color reverses
harlequin color change
small white or yellow papule or vesicles with erythematous bases
erythema toxic (newborn rash)
found along lingual and buccal parts of dental ridges
boons nodules
accumulation of sebaceous gland secretions
milia
symmetric growth restriction involves
head, length, and weight
asymmetric growth restriction involves
only weight
congenital lack of continuity of the esophagus characterized by excessive salvation
esophageal atresia
raised lobulated soft and compressible bright red tumor with sharply demarcated margins, on the head, neck, trunk, or extremities. (tumors occurring in the throat can obstruct the airway) it gradually increases in size for about 6 months then regresses over a period of several years
hemangioma
which test is used to diagnosis congenital hip dysplasia
allis's sign
a common congenital foot anomaly caused by intrauterine positioning. it may be positional (flexible) or structural (fixed).
metatarsus adductus
congenital anomaly marked by one or more extra digits on the hands or feet. more common in african americans.
polydactyly
congenital webbing of the fingers and toes, frequently familial in origin.
syndactyly
an anomaly affecting the sternocleidomastoid muscle, more often on the right side. it is not usually seen until about two weeks of age, when it can be palpated as a firm immobile mass 1-2cm in the mid portion of the muscle. undetected it produces facial asymmetry and limited neck rotation
torticollis
one of the common congenital deformities of the foot, seen more often in male infants than in female, and varying in severity. the forefoot is abducted and points medially, there is pronounced various of the heel, and the foot and toes point downward. in unilateral presentation the affected foot is smaller, with thicken joints
clubfoot (talipes equinovarus)
premature fusion of one or more sutures, stopping bone growth perpendicular to the suture but permitting it parallel to the suture
craniosynostosis
areas of soft (demineralized) bone in the skull, usually in the occipital and parietal bones along the lambdoidal suture. sometimes seen with hydrocephalus
craniotabes
the most commonly seen neck mass in newborns. soft, fluctuant and can range from a few cm to massive. usually seen laterally or over the clavicle and transilluminates well
cystic hygroma
hypoplasia of the mandible causing the tongue to be posteriorly located, resulting in severe upper airway obstruction and cleft palate. physical findings include micrognathia, cleft palate, and low set ears
Pierre Robin sequence
physical findings include prenatal and postnatal growth deficiency, micrognathia, overlapping digits, complex congenital heart disease, low set ears, rocker-bottom clubfeet. associated anomalies include tracheoesophageal fistula or esophageal atresia, hemivertebrae, omphalocele, myelomeningocele, and radial dysplasia
trisomy 18 (edwards sequence)
physical findings include oral-facial clefts, microphthalmia or absence of the eyes, low set ears, rocker-bottom feet, moderate microcephaly, polydactyly, scrap cutis aplasia, and congenital heart disease. identification of multiple midline defects is a recognizing factor
trisomy 13 (patau syndrome)
principal features include hypotonia, poor or absent moro reflex, hyperextensibility of joints, excess skin at the nape of the neck, flat facial profile, low-set ears, slanted palpebral fissures, and single transverse palmar (simian) crease
trisomy 21 (down syndrome)
associated anomalies of trisomy 21 include
-congenital heart defects
-increased incidence of duodenal atresia
-esophageal atresia
-imperforate anus
-significant hearing loss
A condition causing red blood cells to break down in response to certain medications, infections, or other stressors.
glucose-6-phosphate-dehydrogenase deficiency
very rare type of brain damage that occurs in a newborn with severe jaundice. It happens when a substance in the blood, called bilirubin, builds up to very high levels and spreads into the brain tissues. This causes permanent brain damage.
kernicterus
zidovudine effects on the fetus
potential fetal bone marrow suppression, reduces perinatal HIV transmission
phenobarbital effects on the fetus
withdrawal symptoms, hemorrhagic disease
asymmetrical skull shape caused by craniosynostosis of the sutures on one side of the skull
plagiocephaly
A single intramuscular dose of Vitamin K1 Injection of ______ within one hour of birth is recommended.
0.5 to 1 mg
erythromycin ophthalmic ointment application of ______ within one hour of birth is recommended
5mg in 1g
TC bili levels by age
<24hours >10
>24 hours >12
48hours >15
72 hours >17
Normal hematocrit
42-65
Normal WBC
9000-30,000
Normal differential manual neutrophils
1,000-20,000
Normal RBC
3.9-5.9
Normal hemoglobin
13.9-19.9
normal umbilical artery HCO3
23
normal umbilical vein HCO3
21
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