12.8 Learning Activities

Hyperbilirubinemia Case Study^[1]

Use the following information to answer questions 1-6.

Handoff Report:

0903: This is a 12-hour-old female infant, Sofia Garcia, born at 38 weeks gestation via normal spontaneous vaginal delivery. She is exhibiting signs of hyperbilirubinemia with a progressively yellowing skin tone that now extends below the chest and to the extremities.  The infant is feeding well and acting appropriately for age, but her bilirubin levels have continued to rise.  Previous bilirubin level was 10 mg/dL.  The mother is O positive blood type, and baby is A positive.  Vitals signs are as follows: temperature 98.6°F (axillary), heart rate 135 bpm, respiratory rate 45 breaths/min, blood pressure 70/40 mmHg.  The health care provider has been notified and updated, and orders have been given to initiate phototherapy.  Recommendations for your shift include frequent feeding every 2-3 hours, close monitoring of intake and output (including stool and urine color), and serial bilirubin level checks.

 History & Physical:

History

•  Mother is a 28-year-old G1P1, with an unremarkable prenatal course.
•  No history of maternal diabetes or other significant medical conditions.
•  Infant received standard newborn care, including Vitamin K and Erythromycin eye ointment.
•  Breastfeeding initiated shortly after birth, with good latch and suckle.

Physical Findings

• Weight: 3.2 kg (7 lbs 1 oz)
• Length: 50 cm (19.7 in)
• Head Circumference: 34 cm (13.4 in)
•  Jaundice observed, skin is otherwise normal in appearance, with no rashes or lesions.
•  Anterior and posterior fontanelles are soft and flat.
•  Heart and lung sounds are normal.
•  Abdomen is soft and non-tender.
•  No signs of bruising or cephalohematoma.
•   Apgar scores 8 and 9 at 1 and 5 minutes

 Lab/Diagnostic Results:

Provider Orders: 

1. What is the significance of monitoring Sofia’s stool and urine?

a. To assess for signs of infection

b. To ensure she is hydrated and eliminating bilirubin

c. To monitor for signs of meconium aspiration syndrome

d. To evaluate for gastrointestinal disturbances

2. The nurse is explaining to Sofia’s mother about the need for phototherapy. Which statement by the mother indicates a need for further teaching?

a. “The lights help to break down the bilirubin in my baby’s skin.”

b. “I will make sure to keep my baby’s eyes covered with the eye mask during treatment.”

c. “I should stop breastfeeding my baby completely during phototherapy.”

d. “My baby’s skin color will be checked regularly to monitor for improvement.”

3. Which nursing intervention is essential when caring for an infant undergoing phototherapy?

a. Keep the infant in a supine position at all times

b. Shield the infant’s eyes with an opaque mask.

c. Apply a thin layer of lotion to the infant’s skin.

d. Dress the infant in a lightweight onesie to prevent heat loss.

4. The nurse is assessing Sofia for signs of worsening hyperbilirubinemia. Which assessment finding would be the most concerning?

a. Yellowing of the infant’s sclera.

b. Increased frequency of wet diapers.

c. High-pitched cry and lethargy.

d. Refusal of a breastfeeding during one feeding.

5. What should the nurse anticipate as the next step if Sofia’s bilirubin level reaches 20 mg/dL despite phototherapy?

a. Discontinue phototherapy and monitor closely

b. Start intravenous fluids to manage dehydration

c. Consider an exchange transfusion

d. Increase the frequency of feeding to every hour

6. Which outcome would best indicate that the nursing interventions for Sofia Garcia have been effective?

a. The infant has a normal sleep-wake cycle.

b. The infant’s bilirubin levels decrease.

c. The mother reports increased milk production.

d. The infant regains birth weight by the 2-week checkup.

Hydrocephalus Case Study^[2]

Use the following information to answer questions 1-6.

Handoff Report:

0700: This is a 6-hour-old female infant, Sofia Hernandez, born at 35 weeks gestation via vaginal delivery. Sofia has bulging fontanelles and is suspected of having hydrocephalus. Her head circumference is abnormally large for her age, measuring 37 cm.  Vitals signs have shown a trend of increasing heart rate and decreasing respiratory rate over the last few hours, which is concerning for increased intracranial pressure.  Her most recent vital signs are: temperature 98.9°F (axillary), heart rate 170 bpm, respiratory rate 30 breaths/min, blood pressure 70/40 mmHg, and oxygen saturation 98% on room air.  Blood cultures have been drawn and sent to the lab, and a head ultrasound is scheduled to confirm the diagnosis.  Please continue to monitor her neurological status, vital signs, and intake/output closely.  Anticipate a consult with neurosurgery for possible shunt placement.

History & Physical:

History

• Difficult labor and delivery with prolonged rupture of membranes (>18 hours).
• Maternal fever (101.3°F) documented during labor.
• Exhibiting signs of irritability and poor feeding.

Physical Findings

• Head circumference measuring 37 cm.
• Weight 2.2 kg.
• Bulging and tense fontanelles.

Progress Notes:

• 0100: Infant born at 35 weeks gestation via vaginal delivery.  Apgar scores 8 at 1 minute and 9 at 5 minutes.  Infant transitioned to room air successfully.  Head circumference noted to be larger than average at 37cm.  Anterior and posterior fontanelles assessed as bulging and tense.  Notified provider of findings and orders received.  – J. Smith, RN
• 0215: Blood cultures obtained from the client.  Difficult IV start due to client size, successful placement confirmed in left hand on second attempt.  – J. Smith, RN
• 0300: Client increasingly irritable, difficult to console.  Parents are at bedside.  Client offered breast but latched poorly and only nursed for 2 minutes.  Bottle feeding attempted with expressed breast milk, client drank 10mL and refused further attempts. – J. Smith, RN
• 0500: Client vital signs trending with increasing heart rate, now 165, and decreasing respiratory rate, now 32.  Client remains irritable and difficult to console.  Client offered bottle, client drank 5mL and refused further attempts.  Notified provider of client’s status and new vital signs.  – J. Smith, RN

Vital Signs:

Lab/Diagnostic Results: 

Provider Orders: 

a. Bulging fontanelles

b. Head circumference of 37 cm

c. Heart rate of 170 bpm

d. Respiratory rate of 30 breaths/min

2. What is the purpose of drawing blood cultures in this case?

a. To assess for metabolic disorders

b. To evaluate for possible infection, such as sepsis or meningitis

c. To check for electrolyte imbalances

d. To monitor for coagulation abnormalities

3. Based on Sofia’s current condition, which of the following is the priority nursing diagnosis

a. Risk for Infection related to prolonged rupture of membranes

b. Imbalanced Nutrition: Less Than Body Requirements related to poor sucking and swallowing

c. Risk for Impaired Skin Integrity related to fragile skin

d. Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure

4. Which of the following interventions should the nurse implement to minimize further increases in Sofia’s intracranial pressure?

a. Keep Sofia in a supine position

b. Cluster nursing care to allow for longer rest periods

c. Encourage parents to engage in frequent play with Sofia

d. Perform frequent neurological assessments every hour

5. The neurosurgeon has explained the need for Sofia to undergo a shunt placement surgery.  When speaking with the parents, which of the following is the most important information for the nurse to communicate?

a. The surgery is fairly common and has a high success rate.

b. Sofia will have a small scar on her scalp after the surgery.

c. The shunt will help to drain the excess fluid from her brain and relieve pressure.

d. Sofia will need to remain in the NICU for several days after the surgery.

6. After successful shunt placement, which of the following assessment findings would best indicate that the shunt is functioning correctly?

a. Increased urine output

b. Improved feeding and decreased vomiting

c. Decreased head circumference and a softer fontanelle

d. Stable vital signs within the normal range for age