Chapter 12

Hyperbilirubinemia Case Study

Answers

1. Correct Answer: B) To ensure she is hydrated and eliminating bilirubin. The color/amount of stool and urine helps assess hydration and the elimination of bilirubin. Dark urine or pale stools can indicate ineffective bilirubin elimination, which would require further intervention.  Poor intake would also result in decreased urine/stool output, which would also require further intervention. While monitoring for infection is crucial in any newborn, changes in stool and urine color are more directly related to hydration and bilirubin elimination, not infection. Meconium aspiration syndrome (MAS) involves the inhalation of meconium into the lungs, leading to respiratory distress. It is not related to stool and urine color. Although gastrointestinal disturbances can affect stool color/output they usually also present with other signs like vomiting, abdominal distension, or changes in feeding patterns.
2. Correct Answer: C) “I should stop breastfeeding my baby completely during phototherapy.” Phototherapy does not require mothers to stop breastfeeding. Continued frequent breastfeeding is important to help remove bilirubin through bowel movements and is often encouraged during phototherapy.  A, B, and D reflect accurate understandings of phototherapy.
3. Correct Answer: B) Shield the infant’s eyes with an opaque mask. It is crucial to protect the infant’s eyes from the intense light of phototherapy to prevent retinal damage. Option A is incorrect because the infant should be repositioned every 2 hours, even during phototherapy, to prevent skin breakdown and promote even exposure. Option C is incorrect because lotions can interfere with light absorption and increase the risk of burns. Option D is incorrect because infants undergoing phototherapy should be undressed to maximize skin exposure to the light, however, their temperature should be monitored closely for hypothermia.
4. Correct Answer: C) High-pitched cry and lethargy. These are signs of kernicterus, a serious complication of hyperbilirubinemia that can lead to brain damage. While yellowing of the sclera (A) is a common sign of jaundice, it is less concerning than neurological changes. Increased frequency of wet diapers (B) is a positive sign, indicating adequate hydration. Refusal of a single breastfeeding (D) can be concerning but is not as immediate a concern as signs of kernicterus.
5. Correct Answer: C) Consider an exchange transfusion. When a newborn’s bilirubin level reaches 20 mg/dL despite phototherapy, the most appropriate intervention is an exchange transfusion. This is a critical threshold where bilirubin levels pose a risk of causing bilirubin-induced neurologic damage, including kernicterus. Exchange transfusion helps rapidly lower bilirubin levels by removing a large portion of the infant’s blood and replacing it with donor blood, thus reducing the bilirubin load.  Discontinuing phototherapy and simply monitoring the infant is not an appropriate action if bilirubin levels reach 20 mg/dL. While hydration is important for bilirubin excretion, starting intravenous fluids is not the first-line response to a bilirubin level of 20 mg/dL. Intravenous fluids may be indicated if dehydration is present, but they do not directly address the need to manage hyperbilirubinemia at this critical level. Increasing feeding frequency can help with bilirubin excretion, as more frequent feeds promote stooling, which helps eliminate bilirubin. However, this is not sufficient on its own if bilirubin levels are already high (20 mg/dL). Increasing feeding frequency might be part of an overall care plan, but it is not the primary intervention for this level of hyperbilirubinemia.
6. Correct Answer: B) The infant’s bilirubin levels decrease. The most direct and significant indicator of effective nursing interventions is B, the infant’s bilirubin levels decrease. This demonstrates that the treatment, such as phototherapy and frequent feedings, is successfully reducing the bilirubin load in the infant’s system. While the other options, A, C, and D, are positive findings, they are not the most specific or immediate indicators of successful treatment for hyperbilirubinemia.

Hydrocephalus Case Study

Answers

1. Correct Answer: A) Bulging fontanelles. While all the listed options are important to consider for a neonate with suspected hydrocephalus, the most urgent finding is the bulging fontanelles (A). This indicates increased intracranial pressure, which can be life-threatening if not addressed promptly. While a head circumference of 37 cm (B) is abnormal and suggestive of hydrocephalus, it is a static measurement and does not necessarily indicate an immediate emergency.  Similarly, while a heart rate of 170 bpm (C) and a respiratory rate of 30 breaths/min (D) are outside the normal range for a neonate, they need to be interpreted in the context of the client’s overall clinical picture and are not as immediately concerning as the bulging fontanelles.
2. Correct Answer: B) To evaluate for possible infection, such as sepsis or meningitis. Given Sofia’s history and clinical presentation (increasing heart rate and temperature, suspected hydrocephalus, prolonged rupture of membranes, presence of a maternal fever during labor), infection is a significant concern. Sepsis or meningitis could contribute to her signs of increased intracranial pressure or exacerbate her condition. Blood cultures are essential to identify any bacterial or viral infection, which would guide further treatment, including antibiotics or antivirals. Blood cultures are not used to assess for metabolic disorders, electrolyte imbalances or coagulation abnormalities.
3. Correct Answer: D) Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure. This is because her hydrocephalus, as evidenced by the bulging fontanelles, is putting pressure on her brain, which can lead to serious complications if not addressed. While the other diagnoses are relevant, they are not immediately life-threatening. Risk for Infection (A) is a concern due to the prolonged rupture of membranes/maternal fever, but the immediate priority is addressing the increased ICP. Imbalanced Nutrition (B) is also present due to poor feeding, but again, the focus should be on relieving the pressure on the brain. Risk for Impaired Skin Integrity (C) is a potential concern due to the fragile skin of premature infants, but it is not a priority at this time.
4. Correct Answer: B) Cluster nursing care to allow for longer rest periods. Clustering nursing care to allow for longer rest periods is crucial in minimizing increases in ICP.  Infants with hydrocephalus need periods of uninterrupted rest to minimize stimulation.  While frequent neurological assessments (D) are important, they need to be balanced with allowing the infant to rest. Additionally, frequent monitoring will allow for early detection of complications, but it will do nothing to actually prevent increased intracranial pressure. Keeping Sofia in a supine position (A) is not recommended as it can actually increase ICP by obstructing venous drainage. Similarly, encouraging parents to engage in frequent play with Sofia (C) would increase stimulation and potentially worsen her condition.
5. Correct Answer: C) The shunt will help to drain the excess fluid from her brain and relieve pressure. It’s crucial for the parents to understand the fundamental purpose of the surgery, which is to drain the excess fluid from Sofia’s brain and relieve pressure (C). This explanation helps them grasp why the procedure is necessary and its potential benefits. While options A, B, and D provide additional information about the surgery, they are not as critical for the parents to understand at this stage.
6. Correct Answer: C) Decreased head circumference and a softer fontanelle. A decrease in head circumference and a softer fontanelle (C) are the most direct and reliable indicators that the shunt is effectively draining excess cerebrospinal fluid, thus relieving pressure on the brain. While options A, B, and D are positive signs and might be indirectly related to improved intracranial pressure, they are not as specific to the shunt’s function as a decrease in head circumference and a softer fontanelle.

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