Test Your Neonatal Critical Care Knowledge

[SteveNNP]

So, by popular demand..... here is a thread dedicated to questions posed to help increase one's knowledge base in regards to the acute care NICU population. If anyone desperately wants a separate thread dedicated solely to the Well Newborn, we'll have to talk to Elvish about that one

So here's the plan. I'll pose a question drawn from an experience I've had, a clinical scenario I've formulated, or concepts I come across in the literature and board exam review. I will try to keep it in the vein of the NICU nurse, which will be interesting, since I've been saturated in NNP classes for a few years now.

Let's also keep in mind (and we all know this) that practice varies WIDELY from unit to unit. Feel free to answer based on your personal practice, but let's all keep in mind that the "book" answer may be different.

A little about me:

I have been practicing in NICU for almost 5 years, two in a level IIIb, and nearly 3 in a level IIIc quaternary NICU. I have had the privilege of caring for ECMO, pre/postop open hearts, single-lung ventilation, etc, as well as the gamut of preemie and surgical diagnoses. I finished up my NNP grad degree last December, and I'm now in the process of studying for my national certification/boards, as well as looking for a NNP position.

So here goes...

[SteveNNP, MSN, NP]

I'm still here! Sorry... been working a lot lately...haha

The answer is pyloric stenosis. Every other intestinal obstruction whether proximal or distal results in some sort of bilious emesis/aspirates.

Pyloric stenosis usually develops between 2-4 weeks of age.

So let's talk about Hirschprung's disease...

1. How does it present?

2. What neonatal condition is Hirschprung's often associated?

3. What diagnostic tests would you run if you suspected Hirschprung's?

4. Describe briefly the pre and postop nursing care of an infant with Hirschprung's?

[darynash]

Hirschprung's disease usually presents with failure to pass meconium within 24-48 hours of delivery. Imperforate orifice may be associated with Hirschprung's disease. Diagnostically, I would expect a barium enema followed by a rectal biopsy. Preoperatively, I would expect the baby to be NPO and on IV fluids. Also, I would expect enemas to facilitate bowel movements. Postoperatively, I would provide pain management and the baby will be NPO and receiving parenteral nutrition.

[SteveNNP, MSN, NP]

Here are the answers:

1. How does it present?

-failure to pass meconium in the first 48 hours

-history of constipation

-bilious vomiting and abdominal distention

-enterocolitis (rarer)

2. What neonatal condition is Hirschprung's often associated?

-it can be associated with Trisomy 21

3. What diagnostic tests would you run if you suspected Hirschprung's?

-Abdominal xray, usually nonspecific

-Barium enema - shows areas of dilatation and narrowing with a transitional zone

-Rectal biopsy - definitive diagnosis... shows absence of innervation.

4. Describe briefly the pre and postop nursing care of an infant with Hirschprung's?

- Replogle to low suction, NPO, IVF, broad spectrum antibiotics due to increased peritonitis risk, and colonic irrigation.

-Hirschprungs is treated surgically using a colostomy with later pull-through procedure, or a complete pull-through.

-Postop, expect pain management, slow feeds after period of gastric decompression with replogle, ostomy care, also expect bowel dysmotility, stricture formation risk.

[SteveNNP, MSN, NP]

Question:

Why do infants receiving TPN require less total calories and fluids than infants on enteral feeds?

[ittybabyRN, RN]

Question:

Why do infants receiving TPN require less total calories and fluids than infants on enteral feeds?

hmm, because the nutrients/calories are placed directly into the blood stream and sent where needed compared to needing to use energy to digest through the stomach/digestive tract into the bloodstream and to the rest of the body???

[SteveNNP, MSN, NP]

Exactly.

You are attending the delivery of a 29 week c/s secondary to placental abruption. Mom received induction of general anesthesia with a narcotic. The baby arrives to your warmer floppy with no respiratory effort. You provide routine resuscitative measures, but the baby still has minimal resp effort. Your colleague starts to draw up an endotracheal dose of naloxone (Narcan) and prepares to give it to the baby. You tell her to wait....

1) What info is important to know before giving Narcan, especially in a baby of mother who has abrupted?

2) If your colleague had given Narcan, what adverse effects could have potentially occurred to the baby?

[littleneoRN]

Well, you want to know if there is any history or suspected history of narcotic abuse. The Narcan would be an antagonist not only to the narcotic from the general anesthesia but also drugs of abuse in the baby's system, sending him into immediate and abrupt withdrawal.

[darynash]

Giving narcan to a baby that has illegal drugs in their system can cause seizures and in a 29-weeker, then a head bleed. When I did L&D, they always told us never to give narcan to a mom with no prenatal care (may be an illegal drug user). Am I close?

[Humbled_Nurse]

Abruption can possibly be a result of drug abuse in the mother so Narcan would not be indicated.

[SteveNNP, MSN, NP]

Very good! You guys know your stuff!

Here's another one.

Why do we start babies on vanilla TPN or clear IV fluid without electrolytes for the first few days of life?....and what do we look for when getting ready to add electrolytes to TPN?

[gudiarani, BSN, MSN, DNP, RN, NP]

Kidney function, right? And also the existing electrolyte balance before giving electrolytes. The first set of lab values is mostly mom's. We wait for more accurate labs within the first 24 hours to have a better look at the BABY's electrolyte balance.

[gudiarani, BSN, MSN, DNP, RN, NP]

Never heard it called "vanilla TPN"!! haha