CHAPTER 13 NEONATAL AND PEDIATRIC RESPIRATORY CARE
PRETEST QUESTIONS
1. An APGAR score of 5 is determined 5 min after delivery of a term infant. Which of the following should be done at this time?
2. The foramen ovale and ductus arteriosus remain patent in infants with persistent fetal circulation as a direct result of which of the following?
3. Which of the following is not an indication for nasal CPAP in an infant?
4. Which of the following are complications of an umbilical artery catheter (UAC)?
5. Which of the following may occur as a result of cold stress to an infant?
6. An elevation in the levels of chloride in sweat is diagnostic for which of the following lung conditions?
REVIEW
1. The term high-risk infant describes an infant who is at greater risk of death or who has a higher probability of a permanent disability.
a. The Ballard scoring system is one of the most accurate means of estimating the baby’s gestational age.
b. The Ballard system scores the infant on neuromuscular criteria and external physical characteristics.
c. Each specific sign is worth a given number of points, and the infant is given all or part of those points, depending on the assessment of that particular sign or characteristic.
d. Points from each assessed area are totaled and plotted on a graph, which determines the infant’s gestational age.
e. Areas assessed include skin thickness, color and transparency of skin, amount of vernix present on the infant, plantar creases, posture, and muscle tone.
g. The calculated gestational age can then be plotted on a graph, along with the infant’s birth weight, to determine whether the infant is appropriate for gestational age (AGA), small for gestational age (SGA), or large for gestational age (LGA).
c. The Apgar assessment is done at 1 min after delivery to determine whether immediate intervention is required and again at 5 min after birth.
(1) Score of 7 to 10 is normal; requires routine observation, suction upper airway with bulb syringe, dry the infant, and place under a warmer.
(3) Score of 0 to 3 indicates severe asphyxia; requires immediate resuscitation with ventilatory assistance.
e. The 5-min Apgar score is useful in determining the infant’s response to intervention; a score of less than 6 is associated with major complications and treatment in an intensive care nursery.
f. The five assessed signs in the Apgar scoring system may be more easily remembered with the use of the following acrostic:
Exam Note(5) Grunting: An audible expiratory grunt, caused by the infant partially closing the glottis during exhalation to prevent alveolar collapse, is a common sign of respiratory distress in infants.
c. Each assessed area is worth from 0 to 2 points; the lowest score indicates minimal distress (as opposed to the highest score being the best in the Apgar scoring system).
| pH | 7.35 to 7.45 (no less than 7.25 at birth) |
| PaCO2 | 35 to 45 mm Hg |
| PaO2 | 50 to 70 mm Hg |
| HCO3− | 20 to 26 mEq/L |
| BE | −5 to +5 |
a. The O2 hood is the recommended method for delivering O2 in the range of 21% to 100% to the infant.
b. A heated nebulizer connected to an O2 blender is the most common method of O2 delivery. The aerosol tubing connects into the back of the hood. If a blender is used to regulate the O2 percentage, the nebulizer must be set on 100% so that no air entrainment occurs, which would alter the blender percentage.
c. A heated humidifier (Cascade or pass-over) is often used rather than a nebulizer to prevent overhydration of the infant.
d. The percentage of O2 should be analyzed continuously with an O2 analyzer. A port in the top of the hood makes analyzing possible. The O2 percentage should be analyzed as close to the infant’s airway as possible because the percentage of O2 is somewhat higher at the bottom of the hood as opposed to the top.
e. A heated nebulizer or humidifier should be used because cold gas blowing on the infant’s face may induce apnea and colder temperatures in the hood may increase the infant’s O2 consumption.
g. Temperatures inside the hood should be closely monitored through a port in the top of the hood to avoid overheating or underheating the infant.
h. Noise levels inside the hood have been proven to be a source of hearing loss to the infant. To keep noise levels to a minimum, nebulizers that entrain air should not be used because they produce increased noise levels.
a. Nasal catheters and cannulas are available in infant sizes and are most commonly used for long-term O2 therapy in the treatment of bronchopulmonary dysplasia (BPD) and other chronic diseases.
b. The flowmeters used to deliver O2 through the catheter or cannula should be calibrated so that increments of 0.25 and 0.50 L/min can be used.
a. An enclosed device used with neonates that has the capability of controlling FiO2, humidity, and environmental temperature.
c. The FiO2 is controlled with an air entrainment device. A metal red flag is attached to a mechanism that blocks the entrainment port, which allows for an FiO2 of greater than 0.40 when the flag is in the up position. With the flag in the down position, the entrainment port remains open and delivers an FiO2 of 0.4 or less.
d. The oxygen concentration can be inconsistent and variable when the enclosure is opened to provide care to the infant. Because of this, oxygen is often delivered through an oxygen hood placed over the infant inside the incubator.
e. As with oxygen hoods, it is very important to minimize noise levels within the incubator to prevent hearing impairment in the infant.
Exam Note
Exam Note
Exam Note
Decreased venous return is less likely to occur if the infant has decreased static lung compliance caused by respiratory distress syndrome (RDS). Infants with normal lungs would be more susceptible to this complication because the lungs are more compliant and the airway pressure is more easily transferred to the superior and inferior vena cavae.e. Blood must be drawn frequently to determine ABG levels if CPAP is used to monitor PaCO2 levels. If the PaCO2 begins to rise, mechanical ventilation is necessary.
f. The use of nasal CPAP for infants is based on the fact that infants are obligate nose breathers. If the baby cries, CPAP is lost.
d. Initially, the high arterial O2 levels cause constriction of the retinal vessels. As the vessels remain constricted, new vessels form in an attempt to oxygenate the retina.
e. This growth of new vessels leads to hemorrhaging within the retina, retinal detachment, and blindness.
f. The degree of blindness varies in each situation and infants exposed to supplemental O2 should have an eye examination before discharge.
g. ABG samples should be obtained frequently while the infant is receiving O2 to determine the O2 level in the blood. If the infant has a ductal shunt (discussed later in this chapter), the blood must be drawn from the right radial, brachial, or temporal artery to measure the PaO2 of the blood going to the head. If no shunt exists, blood may be drawn from the UAC or any peripheral artery.
b. Insert the catheter into one of the two umbilical arteries. After insertion, determine the position of the catheter with a radiograph.
c. Rest the tip of the catheter in the descending aorta at either one of the following vertebral levels as seen on a radiographic image
d. Secure the catheter in place with umbilical tape or sutures attached to the umbilical stump, and then tape the catheter to the abdomen.
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