A respiratory therapist is called to attend the delivery of a term infant. The mother has had no prenatal care and reports that her “water broke” several days ago. Immediately following vaginal delivery, the infant was placed on a preheated radiant warmer and dried with warmed towels. The infant was placed in a sniffing position and assessed. The following data are available at 1 minute of age:
Respiratory rate: 15 breaths per minute, with weak, irregular effort
Color: Pale, with central cyanosis
Response to stimuli: Grimace
Muscle tone: Limp
Heart rate: 97 beats per minute
1. Which of the following should the respiratory therapist do first?
a. Provide 100% free-flow oxygen
b. Intubate the trachea
c. Provide bag-mask ventilation
d. Initiate chest compressions
2. What is the 1-minute Apgar score?
a. 0
b. 1
c. 3
d. 5
A term (41 weeks) female weighing 3100 g was born to a 30-year-old healthy gravida 2 para 1 mother by cesarean. Apgar scores were 9 and 9 at 1 and 5 minutes. The infant was initially well until day 3 of life, when she presented with tachypnea and increased work of breathing, including retractions and nasal flaring. The infant was transferred to the NICU. A complete sepsis workup was done and antibiotics were given as protocol. The infant was placed on a nasal cannula for oxygen saturations which ranged from 89-91%. A capillary blood gas was performed and revealed the following: pH 7.30, PaCO2 56 mm Hg, PaO2 45 mm Hg, HCO3 27 mEq/L, and BE 1. A chest radio-graph showed mild hyperinflated lungs and mild perihilar interstitial markings. An echocardiogram was also ordered at this time, which showed an anatomically normal heart with no structural malformation. During the next 24 hours, the infant’s respiratory status worsened,
with progressive increases in work of breathing with increasing oxygen requirement. Continuous positive airway pressure was initiated by nasal mask at 6 cm H2O and an FIO2 of 0.50. A follow-up chest radiograph was performed, which showed increasing haziness of both lung fields with air bronchograms. Capillary blood gases obtained 12 hours after nasal CPAP therapy revealed the following: pH 7.19, PaCO2 80 mm Hg, PO2 40 mm Hg, HCO3 29.5 mEQ/L, BE 1.8, and oxygen saturation 88%. Physical assessment revealed the following: tempera-ture 37.1°C, heart rate 175 beats per minute, respiratory rate 90 breaths per minute, and blood pressure 70/40 mm Hg. The infant was
intubated and mechanically ventilated with an inspiratory pressure of 20 cm H2O, PEEP 6 cm H2O, set rate of 60 breaths per minute, and FIO2 of 0.80. Systemic examination was unremarkable except for respiratory distress. There was no clinical evidence of pulmonary hyper-tension. A complete sepsis workup was repeated. The white blood cell count was unremarkable. Chest radiograph following intubation
revealed diffuse ground-glass appearance with air bronchograms. The endotracheal tube was 2 cm above the carina.
1. What therapeutic recommendation would you make based on the infant’s clinical presentation and chest radiograph?
2. Given this presentation, what diagnosis should be considered for this infant?
3. What information obtained by chest radiograph would indicate that this infant may benefit from
surfactant replacement therapy?
You are called to the delivery room at 2:00 a.m. for a laboring gravida 1 para 0 mother at 28 weeks’ gestation. The mother had good an-
tenatal care and had a normal integrated prenatal screening (IPS), normal 20-week ultrasound, and protective serology, including rubella immune, human immonodeficiency virus (HIV) negative, venereal disease research laboratory (VDRL) negative, hepatitis negative. Group B Streptococcus (GBS) status is unknown as the woman had not yet had swabs done. Social history was negative for tobacco, alcohol, or recreational drug use during the pregnancy. She has gestational diabetes mellitus, which was reasonably controlled by diet and exercise
alone. You arrive to the delivery room moments before the baby is born and prepare equipment for a potential resuscitation, which includes oxygen, bag and mask, suction, towels to dry, and intubation equipment. At birth, the newborn cries spontaneously. She is placed on the warmer to be dried and stimulated; her heart rate is 120 beats per minute and her respiratory rate is 60 breaths per minute. The
infant grunts intermittently. At 4 minutes of age, the newborn has both subcostal and intercostal retractions, nasal flaring, and continuous grunting. Her respiratory rate is now 82 breaths per minute and her heart rate is 190 beats per minute. Oxygen saturation by pulse oximetry is 84% with blow-by oxygen. You begin providing CPAP at 6 cm H2O by mask with a t-piece resuscitator. A systolic murmur gr 2/6 is auscultated loudest at the left upper sternal boarder (LUSB). The infant is transferred to the NICU where she continues to receive nasal CPAP at 6 cm H2O and an FiO2 of 0.45. The chest X-ray shows diffuse ground-glass appearance with air bronchograms. An arterial umbilical catheter (UAC) is inserted. Arterial blood gas reveals the following: pH 7.23, CO2 60, PaO2 40, HCO3 27, BE +1, and lactate 4.8.
Blood work shows white blood cell count 20.3, neutrophils 12.3, no left shift, hemoglobin 16.5, platelets 260.
1. What is the first line of therapy for this premature infant considering her presentation?
2. What are the chemical components that make up surfactant?
3. How does surfactant work in the lung?
Dylan’s mother is only four weeks postpartum, and in addition to her physical and emotional need, she has to cope with the extraordinary need of a child with Down syndrome and congenital heart disease. She may experience postpartum “blues” or postpartum depression. Discuss and describe postpartum “blues” and depression. How may the nurse identify these conditions? What (if any) referrals should be made? How can the nurse be of the most help to this mother? How will the condition of the mother affect the health care of Dylan? Be spec
Can someone offer an example for this assignment. Looking for something dealing with healthcare. Trying to figure out how to get started. For this assignment, you will draft a Legislative Letter to a specific legislator and offer support or a constructive argument against pending or passed policy or legislation that you are passionate about.
The Biased Care Model offers different routes to improve clinical care that can be utilized. Provide an example of a biased perception in minority healthcare that may impact patient outcomes and how use of the Biased Care Model can help to facilitate change and improve clinical care.
You are working at a primary care office, when Mr. Jackson, a 35-year-old male, presents for a routine well visit. His medical history includes asthma for which he is currently prescribed an albuterol (Ventolin) inhaler. During your data collection, Mr. Jackson reveals that he feels that his asthma is not very well controlled. He reports using his rescue inhaler at least 3 to 4 days per week. He expresses frustration over the fact that he feels that his asthma affects his daily activities. The health care provider evaluates Mr. Jackson and decides to prescribe a fluticasone (Flovent) inhaler in addition to his albuterol (Ventolin).
-How does the fluticasone (Flovent) inhaler differ from the albuterol (Ventolin) inhaler Mr. Jackson is already prescribed?
-What patient teaching should be provided to Mr. Jackson about his fluticasone (Flovent) inhaler?
-In addition to his medications, what are some additional ways Mr. Jackson may be able to manage his asthma symptoms?
Define a specific population of women.
Case Study
Chapter 13 Central Nervous System Stimulants and Related Drugs
Nancy has been unsuccessful in preventing migraine headaches and has been prescribed a selective serotonin receptor agonist (SSRA), sumatriptan (Imitrex).
Question 1
What patient teaching would be included for Nancy regarding the action and route of administration of sumatriptan?
Question 2
What patient teaching should be included for Nancy regarding adverse effects or contraindications?
Question 3
What medications would Nancy have been prescribed for first- and second-line preventive therapy?
Question 4
Nancy asks the nurse about the effects of caffeine on migraines. What should the nurse’s response be?
Question 5
Nancy also asks the nurse if there are effective nonpharmacologic treatments for migraines. What evidence-based answer can the nurse provide?
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