N303 - Ch 39 Ob

Front 1

What basic problems can affect newborns?

Back 1

1. Problems r/t gestational age or intrauterine growth that does not follow normal patterns, such as preterm birth

2. Acquired problems resulting from maternal or newborn physiologic factors, such as ABO incompatibility or RDS

3. Physical problems, such as congenital anomalies or birth defects

Front 2

What is hyperbilirubinemia?

Back 2

Increased levels of bilirubin level in the blood

Front 3

What are the characteristics of hyperbilirubinemia?

Back 3

Yellow discoloration of the skin, mucous membranes, sclera, and various organs

Front 4

What is the yellow discoloration of the skin, mucous membranes, sclera, and various organs called?

Back 4

Jaundice (or icterus)

Front 5

What causes jaundice?

Back 5

The accumulation in the skin of unconjugated bilirubin, a breakdown product of hemoglobin formed after its release from hemolyzed RBCs

Front 6

What is physiologic jaundice?

Back 6

Jaundice that arises more than 24 hours AFTER birth and occurs in about half of all healthy term newborns and in 80% of preterm infants

Front 7

What is pathologic jaundice?

Back 7

Jaundice that occurs before 24 hours of birth with a serum bilirubin concentration of greater than 4 mg/dl in cord blood

Front 8

What are the risk factors of hyperbilirubinemia?

Back 8

1. Gestational age less than 38 weeks
2. Breastfeeding
3. Previous sibling with significant jaundice
4. Jaundice appearing before discharge

Front 9

What maternal factors are potential causes of pathologic hyperbilirubinemia in neonates?

Back 9

1. Rh and ABO incompatibility
2. Maternal infections
3. Maternal diabetes
4. Oxytocin administration during labor
5. Maternal ingestion of sulfonamides, diazepam, or salicylates near time of birth

Front 10

What fetal/newborn factors are potential causes of pathologic hyperbilirubinemia in neonates?

Back 10

1. Prematurity
2. Hepatic cell damage by infection or drugs
3. Neonatal hyperthyroidism
4. Polycythemia
5. Intestinal obstruction such as meconium ileus
6. Pyloric stenosis
7. Biliary atresia
8. Sequestered blood (e.g. from cephalhematomas, ecchymosis, or hemangiomas)
9. Maternal blood swallowed by neonate

Front 11

When would hemolytic diseases of the newborn occur?

Back 11

If the blood groups of the mother and the baby are different

Front 12

What is the most common hemolytic disease?

Back 12

ABO and Rh factor incompatibilities

Front 13

What is isoimmunization?

Back 13

Rh incompatibility, in which an Rh-negative mother has an Rh-positive fetus who inherits the dominant Rh-positive gene from the father

Front 14

What is the prevalence of Rh incompatibility?

Back 14

From 10% to 15% of all Caucasian couples and about 5% of African-American couples have Rh incompatibility; it is rare in Asian couples

Front 15

What happens if an Rh-negative mother is pregnant with her first Rh-positive child?

Back 15

Usually, she becomes sensitized but does not produce enough antibodies to cause lysis (destruction) of fetal blood cells. The baby is born without sustaining any damages.

Front 16

What happens if an Rh-negative mother is pregnant with another Rh-positive child?

Back 16

Since she is already sensitized, antibodies form in response to repeated contact with the antigen from the fetal blood, and lysis of the fetal RBCs results, which can lead to fetal hemolytic anemia

Front 17

How does maternal sensitization occur?

Back 17

The mother forms antibodies against the fetal blood cells - first IgM antibodies that are too large to pass through the placenta, and then later, IgG antibodies that can cross the placenta to destroy the "foreign" fetal cells

Front 18

When can sensitization occur?

Back 18

During pregnancy, birth, miscarriage or induced abortion, amniocentesis, external cephalic version, or trauma

Front 19

What is erythroblastosis fetalis?

Back 19

Condition in which fetus compensates for hemolytic anemia by producing large numbers of immature erythrocytes to replace those hemolyzed

Front 20

What is hydrops fetalis?

Back 20

The most severe form of hemolytic anemia, in which the fetus has marked anemia, cardiac decompensation, cardiomegaly, hepatosplenomegaly, and may experience hypoxia. In addition, because of the decrased intravascular oncotic pressure involved, fluid may leak out of the intravascular space and cause localized edema.

Front 21

What is intrauterine transfusion?

Back 21

The infusion of Rh-negative, type O blood into the umbilical vein

Front 22

What is intrauterine transfusion?

Back 22

The infusion of Rh-negative, type O blood into the umbilical vein

Front 23

What is more common than Rh incompatibility?

Back 23

ABO incompatibility

Front 24

What is ABO incompatibility?

Back 24

If the fetal blood type is A, B, or AB and the maternal blood type is O. The incompatibility arises because naturally occurring anti-A and anti-B antibodies are transferred across the placenta to the fetus.

Front 25

What test is indicative of ABO incompatibility?

Back 25

A positive Coomb's test (usually weakly positive results)

(also known as DIRECT ANTIGLOBULIN TEST [DAT])

Front 26

What is the goal of care given to the infant with hyperbilirubinemia?

Back 26

Prevention of acute bilirubin encephalopathy, which is caused by the deposition of bilirubin in the brain, especially within the basal ganglia, the cerebellum, and the hippocampus

Front 27

Why does deposition of bilirubin in the brain occur?

Back 27

Because unconjugated bilirubin is highly lipid soluble, making it capable of crossing the BBB if it is not bound to protein

Front 28

What happens when concentrations of unconjugated bilirubin reaches toxic levels?

Back 28

Yellowish staining of the brain tissue and necrosis of neurons occur, which ultimately leads to hyperbilirubinemia

Front 29

What is the upper limit of serum bilirubin levels in a term infant?

Back 29

25 mg/dl

Front 30

What happens if serum bilirubin levels exceed 25 mg/dl?

Back 30

The risk for acute bilirubin encephalopathy increases, although the condition may occur at much lower levels in premature infants or infants with other complications

Front 31

What is the mean peak of unconjugated bilirubin levels in high risk, LBW infants associated with acute bilirubin encephalopathy?

Back 31

10 to 12 mg/dl

Front 32

What perinatal events increase the likelihood of acute bilirubin encephalopathy development?

Back 32

1. Hypoxia
2. Asphyxia
3. Acidosis
4. Hypothermia
5. Hypoglycemia
6. Sepsis
7. Treatment with certain medications
8. Hypoalbuminemia

Front 33

Is acute bilirubin encephalopathy present at birth?

Back 33

No, clinical manifestations typically appear between 2 and 6 days after birth and go through several phases as the disease progresses

Front 34

What is the first phase of acute bilirubin encephalopathy?

Back 34

1. The newborn is hypotonic and lethargic and shows a poor suck and depressed or absent Moro reflex

2. Followed by the appearance of a high-pitched cry, opisthotonos (severe muscle spasm that causes the back to arch acutely), spasticity, hyperreflexia, and often by fever and seizures

Front 35

What is opisthotonos?

Back 35

Severe muscle spasm that causes the back to arch acutely

Front 36

What permanent sequelae are result from acute bilirubin encephalopathy?

Back 36

1. Extrapyramidal movement disorders (especially dystonia and athetosis)

2. Gaze abnormalities (especially upward gaze)

3. Auditory disturbances (especially sensorineural hearing loss)

4. Intellectual deficits (rarely in the mental retardation range)

5. Enamel dysplasia of the deciduous teeth

Front 37

What is kernicterus?

Back 37

The chronic and permanent results of bilirubin toxicity

Front 38

What events could cause a woman to develop antibodies to the Rh factor?

Back 38

1. Previous pregnancy with an Rh-positive fetus

2. Transfusion with Rh-positive blood, which causes immediate sensitization

3. Miscarriage or induced abortion after 8 or more weeks of gestation

4. Amniocentesis performed for any reason

5. Premature separation of the placenta

6. Trauma

Front 39

What is Rh0 (D) immune globulin?

Back 39

A commercial preparation of passive antibodies against the Rh factor

Front 40

What is the function of an injection of the Rh0 (D) immune globulin?

Back 40

Anti-Rh antibodies destroys any fetal RBCs in the maternal circulation by causing the cells to be phagocytosed before the woman's immune system is activated to produce antibodies

Front 41

What is the Coomb's test?

Back 41

The maternal blood serum is mixed with Rh-positive erythrocytes. If the Rh-positive erythrocytes agglutinate or clump, this indicates that maternal antibodies are present or that the mother has been sensitized.

Front 42

If a woman has an initial negative Coomb's test, when should it be repeated?

Back 42

At 28 weeks

Front 43

How can hyperbilirubinemia be prevented?

Back 43

1. Prenatal control of DM
2. Prevention of maternal infection
3. Avoidance of drugs such as diazepam and salicylates near the time of birth
4. Prevention of preterm birth

Front 44

What are the doses of Rh0 (D) immune globulin available?

Back 44

50 mcg, 300 mcg, and more than 300 mcg

Front 45

When should 50 mcg of Rh0 (D) immune globulin be administered?

Back 45

After chorionic villus sampling, ectoptic pregnancy, miscarriage, or abortion after 13 weeks of gestation

Front 46

When should more than 300 mcg of Rh0 (D) immune globulin be administered?

Back 46

1. After a large transplacental hemorrhage

2. After a mismatched blood transfusion

Front 47

When should an unsensitized mother whose baby is Rh-positive receive 300 mcg of Rh0 (D) immune globulin?

Back 47

Within 72 hours of birth

Front 48

What increases the newborn's risk for severe hemolytic disease and susceptibility to kernicterus?

Back 48

1. Perinatal asphyxia
2. Acidosis
3. Cold stress
4. Sepsis
5. Hypoglycemia

Front 49

What will facilitate the removal of bilirubin in newborns with hyperbilirubinemia?

Back 49

Early feeding to stimulate stooling

Front 50

What is used to reduce rapidly increasing serum bilirubin levels?

Back 50

Phototherapy

Front 51

What blood type should an infant with Rh incompatibility be transfused with?

Back 51

Type O Rh-negative, so the maternal antibodies still present in the infant do not hemolyze the transfused blood

Front 52

What is the maximum amount of blood that an infant can be exchanged with?

Back 52

500 ml

Front 53

What must be monitored while an infant is undergoing exchange transfusion?

Back 53

1. Heart rate and rhythm
2. Respirations
3. BP
4.Temperature
5. Pedal pulses
6. Presence of edema

Front 54

What is often given during an exchange transfusion?

Back 54

Calcium gluconate because donor blood lowers the infant's serum calcium

Front 55

What is a congenital disorder?

Back 55

A disorder that is present at birth and can be caused by genetic or environmental factors, or both

Front 56

What are the most common congenital anomalies?

Back 56

1. Congenital heart disease
2. Neural tube defects
3. Cleft lip or palate
4. Clubfoot
5. Developmental dysplasia of the hip

Front 57

What is the prevalence of congenital heart disease?

Back 57

8 in 1000 live births

Front 58

What is the etiology of congenital heart disease?

Back 58

Unknown in more than 90% of cases

Front 59

What maternal factors are known to be associated with a higher incidence of congenital heart disease?

Back 59

1. Viral infections such as rubella
2. Ingestion of folic acid antagonists, progesterone, estrogen, lithium, warfarin (Coumadin), or anticonvulsants
3. Use of the acne medication isotretinoin (Accutane)
4. Alcohol intake
5. Poor nutrition
6. Radiation exposure
7. Complications of pregnancy such as antepartal bleeding
8. Metabolic disorders such as DM and phenylketonuria
9. Systemic lupus erythematosus
10. Maternal age > or = 40 years

Front 60

What else is congenital heart disease associated with?

Back 60

Other extracardiac defects such as renal agenesis, tracheoesophageal fistula, and diaphragmatic hernias

Front 61

What abnormal respiratory findings are associated with cardiac disease?

Back 61

1. Tachypnea (RR > 60-120 breaths/min)
2. Retractions with nasal flaring
3. Grunting occurring with or without exertion
4. Dyspnea

Front 62

What environmental factors are implemented with neural tube defects?

Back 62

1. Treatment with valproic acid (an anticonvulsant)
2. Treatment with methotrexate (a chemotherapeutic medication)
3. Alcohol consumption
4. Excessive maternal body heat exposure during the early trimester (such as significant febrile illness or extensive hot-tub exposure)

Front 63

What is an encephalocele?

Back 63

A herniation of the brain and meninges through a skull defect

Front 64

What is the most common defect of the CNS?

Back 64

Spina bifida

Front 65

What is spina bifida occulta?

Back 65

A malformation in which the posterior portion of the laminas fails to close, but the spinal cord or meninges do not herniate or protrude through the defect

Front 66

What us spina bifida cystica?

Back 66

A malformation in which the posterior portion of the laminas fails to close, and the spinal cord or meninges herniate or protrude through the defect, along with CSF and nerves

Front 67

What assessments are made of the infant's neurologic function in infants with spina bifida?

Back 67

1. Any apparent paralysis of lower extremities
2. Flaccidity or spasticity of muscles below the defect
3. Sphincter control, as evidenced by the number and character of voidings and stools

Front 68

What is hydrocephalus?

Back 68

A condition in which the ventricles of the brain are enlarged as a result of an imbalance between the production and absorption of the CSF

Front 69

What should a nurse be alert for with infants with hydrocephalus?

Back 69

Projectile vomiting, because of increased intracranial pressure, and maintain aspiration precautions

Front 70

What is microcephaly?

Back 70

Refers to a head circumference that measures more than three standard deviations below the mean for age and sex

Front 71

What can cause microcephaly?

Back 71

1. Autosomal recessive disorder
2. Chromosomal abnormality
3. Fetal exposure to teratogens such as radiation
4. Alcohol ingestion
5. Congenital infections such as rubella, toxoplasmosis, or cytomegalovirus

Front 72

What causes respiratory distress at birth or shortly thereafter?

Back 72

1. Lung immaturity or anomalous development

2. Diaphragmatic hernia or tracheoesophageal fistula

Front 73

What is the prevalence of a cleft lip?

Back 73

1 in 700 live births

Front 74

What is esophageal atresia?

Back 74

A congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thus failing to form a continuous passageway to the stomach

Front 75

What is an omphalocele?

Back 75

A covered defect of the umbilical ring into which varying amounts of the abdominal organs may herniate

Front 76

What is gastroschisis?

Back 76

The herniation of the bowel through a defect in the abdominal wall to the right of the umbilical cord

Front 77

What is clubfoot?

Back 77

A congenital deformity of the foot and ankle that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus

Front 78

What is talipes varus?

Back 78

An inversion or bending inward

Front 79

What is talipes valgus?

Back 79

An eversion or bending outward

Front 80

What is talipes equines?

Back 80

Plantar flexion in which the toes are lower than the heel

Front 81

What is talipes calcaneus?

Back 81

Dorsiflexion, in which the toes are higher than the heel

Front 82

What is hypospadias?

Back 82

An abnormally located urinary meatus (pee hole)

Front 83

What is a syndrome?

Back 83

A recognized pattern of malformations

Front 84

What is the most common syndrome?

Back 84

Down's syndrome

Front 85

What is the prevalence of Down's syndrome?

Back 85

1 in 660 live births

Front 86

What is a Simian crease?

Back 86

A single lined crease on the palm of the hands of infants with Down's syndrome

Front 87

What causes phenylketonuria?

Back 87

A deficiency of the enzyme phenylalanine dehydrogenase