Case Study- Small for Gestational Age

A 2300 gm (5lb, 1.5 oz) infant is by spontaneous vaginal delivery. The infants length is 44 cm (17.5
in), and her head circumference is 30.5 cm (12 in). No abnormalities are noted on physical
examination. Maternal history and a gestational age assessment reveal the neonate to be at
approximately 38 weeks gestation and that she is SGA.

What might you expect to find in the mothers history?
a. Positive culture for gonorrhea
b. Weight gain of 15.9 kg (35lb)
c. A history of smoking one pack of cigarettes per day
d. Documented class A diabetes

What implications do the infants measurements have?
a. The insult occurred late in gestation
b. The insult occurred early in gestation
c. The insult occurred during labor and delivery
d. The infant can catch up in weight with adequate nutrition

To which of the following should the nurse be alert when caring for this infant?
a. Projectile vomiting
b. Possible skull fracture
c. Positive drug screen
d. Hypothermia

Which characteristic best describes a SGA infant?
a. Lack of movement in the upper extremities
b. Long fingernails that extend over the ends of the fingers
c. Round face and red skin
d. Wasted and thin at birth with loose and scaling skin
















Case Study- Large for Gestational Age

A 4200 gm (9 lb 3 oz) boy is born after a difficult forceps delivery. The prenatal history reveals an
uncomplicated pregnancy of 40 weeks gestation. The infants length is 53.3 cm (21 in), and his head
circumference is 37 cm (14.6 in). Gestational age assessment reveals the infant to be LGA.

On physical examination, what might you expect to find with this infant?
a. Club feet
b. Brachial plexus injury
c. Thin and transparent skin
d. Diminished Babinski reflex

In actuality, the nurse finds the infant has a fractured clavicle, which is confirmed by x-ray. What
assessment finding may have led the nurse to this conclusion?
a. Asymmetrical startle reflex
b. Drooping left eye lid
c. Extreme jitteriness
d. History of forceps delivery

For what should the nurse be alert when caring for this infant?
a. Hypothermia
b. Congenital anomalies
c. Respiratory distress
d. Hypoglycemia

The LGA infant may experience which of the following problems?
a. Patent ductus arteriosus
b. Facial nerve damage
c. Hypercalcemia
d. Poor suck, swallow, and breathing coordination
















Case Study- Preterm Infant

A woman has delivered a 2000 gm (4 lb, 6.5 oz) infant by cesarean section. The infant is assessed to be
appropriated for his gestational age of 34 weeks. No abnormalities are noted on physical examination.

This infant is a risk for which of the following conditions?
a. Hyperglycemia
b. Premature closure of the ductus arteriosus
c. Respiratory distress syndrome
d. Imperforate anus

What might the nurse expect to find in the mothers history?
a. Premature labor treated with tocolytics
b. Gestational diabetes
c. Previous infant with Down syndrome
d. Exposure to rubella in the first trimester

Why is hyperbilirubinemia of special concern in preterm infant?
a. Immature liver function
b. Poor vascular system
c. Decreased respiratory function
d. Immature endocrine function

Gavage feedings are frequently needed to meet the nutritional needs of preterm infants because:
a. Lactose enzyme activity is not adequate
b. Suck, swallow, and breathing reflexes are uncoordinated
c. Renal solute load must be considered
d. Hyperbilirubinemia is likely


Characteristics of Preterm infant: more brown fat, thin, non flexed, frail skin.
















Case Study- Meconium Aspiration Syndrome/Postterm Infant

A 3250 gm (7 lb, 3 oz) infant has been delivered through meconium-stained fluid at 42 weeks
gestation. The infants initial presentation is that she is limp, is cyanotic, has minimal respirations, and
has a heart rate below 100 bpm. Her oropharynx was suctioned while the head was on the perineum,
and she was intubated and suctioned by the neonatal team. No meconium was seen below the vocal
cords. With oxygen and stimulation, her apgar scores were 8 and 9.

What is the most serious consequence that might result from this delivery?
a. Patent ductus arteriosus
b. Meconium aspiration
c. Hyaline membrane disease
d. Depressed skull fracture

What would the nurse expect to see on examination of this infant?
a. Abundant lanugo
b. Absence of sole creases
c. Leathery, cracked, and wrinkled skin
d. Large caput succedaneum

A neonate was born with greenish discoloration of the nails and skin and greenish secretions in the
nasal passages. Why might the infant be transferred to a level 3 nursery?
a. To determine the reason for the postmaturity
b. To observe more closely for skin color changes
c. To manage severe respiratory problems that may develop
d. To manage the pulmonary hypotension that is likely to develop



















Case Study- Persistent Pulmonary Hypertension of the Newborn

A 35 weeks gestation infant was born 6 hours ago to a diabetic mother. The infant required
resuscitation at birth and apgar scores were 4, 7, and 8; weight is 3000 grams. The infant is now
experiencing tachypnea, nasal flaring, and retractions. Cyanosis is developing and it becomes worse
when the infant is handled.

This infant is at risk of developing PPHN due to which of the following factors? Select all that apply
a. Prematurity
b. Maternal diabetes
c. Small for gestational age
d. Asphyxia in utero

PPHN occurs when there is:
a. Increased vascular resistance of the lungs after birth
b. Decreased vascular resistance of the lungs after birth
c. Left to right shunting of blood in the heart
d. Constriction of the ductus arteriosus

Important nursing considerations for this infant include: Select all that apply
a. Ensuring minimal handling and noise
b. Monitoring closely for signs of hyperglycemia
c. Cold stress will decrease oxygen demand
d. Surfactant therapy may be necessary





















Case Study- Transient Tachypnea of the Newborn

A 39 weeks gestation male infant was born via scheduled cesarean section 1 hour ago. The newborns
apgar scores were 8 and 9 and he weighs 4500 grams. He was transitioning well but now he is
experiencing nasal flaring, grunting and his respiratory rate is 74.

Which of the following infants is at greatest risk for developing TTN?
a. Spontaneous vaginal delivery; 40 weeks gestation
b. Cesarean section delivery; 41 weeks gestation
c. Induced vaginal delivery; 41 weeks gestation
d. Vaginal delivery with maternal anesthesia; 38 weeks gestation

Symptoms of TTN include all of the following except:
a. Tachypnea
b. Hyperinflation of lungs
c. Air trapping in the bronchovascular spaces
d. Retractions

TTN is the result of:
a. Lack of fluid in the fetal lungs
b. Extreme prematurity
c. Delayed absorption of fetal lung fluid
d. Over active surfactant production






















Case Study- Respiratory Distress Syndrome

A male infant has been delivered vaginally at 35 weeks gestation. The infant weighed 2500 gm (5 lb 8
oz); the fetal heart rate appeared fine during labor; an L/S ratio was reported at 1.8/1. His mother has
gestational diabetes.

Surfactant production for an infant with RDS will be inhibited owing to which of the following?
a. Prematurity
b. Water intoxication
c. Alkalosis
d. Drugs given to the mother

Which of the following is characteristic of neonates with RDS?
a. Have a deficiency of pulmonary surfactant
b. Are postmature
c. Have sternal excursions
d. Demonstrate tachypnea and expiratory grunting
e. A and D

Which of the following statement(s) is (are) true about RDS? Select all that apply
a. It is characterized by atelectasis
b. Acidosis perpetuates the decreased production of surfactant
c. It may be induced by hypothermia in a preterm infant
d. With adequate supportive care, it is self-resolving in approximately 72 hours

Which of the following prenatal factors predispose the neonate to development of respiratory distress
syndrome?
a. Maternal diabetes: because of decreased production of surfactant.
b. 42 weeks gestation
c. 31 weeks gestation
d. Maternal hypertension















Case Study- Hyperbilirubinemia

A 40 weeks gestation infant was delivered after a 16-hour induced labor. Review of the mothers
prenatal and labor history yielded the following information: Blood type A+; VDRL nonreactive; AFP
normal. The infant had the umbilical cord wrapped twice around her neck and required bag-mask
ventilations to initiate breathing. Apgar scores were 7 and 8.

From this information, which of the following factors place the infant at increased risk for
hyperbilirubinemia?
a. 16 hours of labor
b. Postmaturity
c. Mothers blood type is A+
d. Need for resuscitation

One her second day of life, the infant required phototherapy treatment.

While the infant is under the phototherapy lights, it is important to do which of the following?
a. Keep the infant under the lights continuously so that there will be maximal effectiveness in
the shortest period
b. Limit any unnecessary touch stimulation because the infants metabolism is already high
and touch might further increase it
c. Discontinue breastfeeding because the fluid content of breast milk is deficient for a neonate
undergoing phototherapy
d. Prevent hypothermia, hyperthermia, or both in this infant

A neonate is under phototherapy for elevated bilirubin levels. The babys stools are now green and
loose. Which of the following actions should the nurse take at this time?
a. Discontinue the phototherapy
b. Notify the health care provider
c. Take the babys temperature
d. Assess the babys skin integrity















Case Study- Infant of Diabetic Mother

A 39 weeks gestation, G3 P2 has gestational diabetes. She delivers a 10 lb, 6 oz infant via cesarean
section after several hours of labor and a failure of the fetus to descend. The infants apgar scores were
7 and 9. The infant has a respiratory rate of 68, temperature of 97.2 and is jittery.

Maternal hyperglycemia results in fetal:
a. Distress
b. Hypotension
c. Hypoglycemia:
d. Hyperinsulinism:

Infants of diabetic mothers are especially at risk for shoulder dystocia when:
a. The first stage of labor is prolonged
b. It is a preterm delivery
c. The mother is a primigravida
d. The baby is macrosomic

Newborn injury associated with shoulder dystocia may include: Select all that apply
a. Brachial plexus injury
b. Fracture of the clavicle
c. Hypoglycemia
d. Hypoxia






















Answer the following questions for each case study:

What is the therapeutic management (include interventions, meds, treatments, psychosocial factors)?
HYPERBILIRUBINEMIA: Phototherapy and Exchange Transfusions
TTN: O2 therapy, IV feedings, and Antibiotics may be given until sepsis is ruled out.
SGA: treat specific s/s presented, monitor glucose, and temperature.
LGA: prepare for c-section, prepare for baby and maternal injury, good assessments.
PRETERM: humidified o2, suction, positional changes, monitor s/s of deterioration, promote rest, monitor for infection, medications:
electrolytes. Treatments: IV fluids, Gavage feedings. Psychosocial: weak cry, decrease stimulation, maintain neutral thermal
environment.
MECONIUM ASPIRATION: infant will be heavily sedated, increase stimuli, notify physician
PERSISTANT PULMONARY HYPERTENSION: Treat underlying cause, sedation, ventilation, inhaled nitrous oxide, echmotherapy for
lifesaving interventions.
RESPIRATORY DISTRESS: surfactant replacement therapy, o2, c-pap, mechanical ventilation, inhaled nitrous oxide.
INFANT OF A MOTHER WITH DIABETES:



What are the nursing considerations?
HYPERBILIRUBINEMIA: skin assessment q 8 hours, Maintain thermal Environment, Frequent neonatal assessments, Provide optimal
Nutrition, Protecting the eyes, enhancing response to therapy, detecting complications, and teaching parents.
TTN: Identify s/s then, notify the physician
SGA: Monitor temperature and glucose, wake baby to feed, observe for jaundice. More SGA infants are more likely to have fetal distress.
LGA: post partum hemorrhage, congenital anomalies, and regular vitals.
PRETERM: prevent complications, monitor for change in status, change ventilators settings, and promote bonding with parents. Maintain
normal levels of o2.
MECONIUM ASPIRATION: have o2 and suction ready, and assess regularly.
PERSISTANT PULMONARY HYPERTENSION:
RESPIRATORY DISTRESS: observe for changes in conditions, and ventilator settings, observe for complications.
INFANT OF A MOTHER WITH DIABETES: warmer and resuscitation equipment ready, vitals q 15 mins mom and baby for first 4
hours,


What is the primary nursing diagnosis for the client in the scenario?
HYPERBILIRUBINEMIA: Impaired Skin Integrity related to frequent loose stools
TTN: Ineffective Airway Clarence
SGA: R/F hypoglycemia, Ineffective-breathing pattern. R/F ineffective thermoregulation
LGA: R/F Injury r/t LGA forceps delivery.
PRETERM: Activity intolerance, ineffective feeding pattern, and imbalanced nutrition: less than body requirements, R/F unstable
Glucose. Ineffective feeding is primary.
MECONIUM ASPIRATION: R/F ineffective airway clearance r/t meconium aspiration.
PERSISTANT PULMONARY HYPERTENSION: ineffective tissue perfusion.
RESPIRATORY DISTRESS: Ineffective breathing pattern
INFANT OF A MOTHER WITH DIABETES: r/f unstable glucose