Maternal Infant Care and Anomalies

Question 1

Intimate Partner Violence

Level 1,2,3

Answer 1

Level 1 – Maltreatment is occasional; consists of slapping, punching, kicking, verbal maltreatment. Contusions occur.

Level II – Maltreatment is becoming more frequent; beatings are sustained and cause fractures, such as broken jaw or rib fractures.

Level III – Maltreatment is even more frequent, perhaps daily. A weapon, such as a gun, baseball bat, or broom handle may be used. Permanent disability or death from injuries, such as intracranial hemorrhage or concussion may occur.

Question 2

Intimate Partner Violence

Cycle of Violence

Answer 2

Build up phase - increased tension
Stand over phase - control, fear
Explosion
Remorse phase - justification, minimilization, guilt
Pursuit phase – pursuit and promises, helplessness, threats
Honeymoon phase - enmeshment, denial of previous difficulties

Question 3

Characteristics of the abuser and the abused

Answer 3

1 cause of death during pregnancy is homicide from intimate partner violence

Prevalence of IPV witnessed
Abused as a child
Alcohol may contribute -> poor impulse control
Learned helplessness

Question 4

Partner Violence Screening tool

Advocacy – universal screening of all patients at every health care encounter

Answer 4

Have you been hit, kicked, punched, or otherwise hurt by someone in the past year?

Do you feel safe in your current relationship?

Is there a partner from a previous relationship who is making you feel unsafe now?

Question 5

Transcultural Care

Answer 5

Health care values and beliefs
Health maintenance during pregnancy
Modesty, Fate
Childbirth, Childrearing

Health care practices
Rituals for preventing illness, restoring health
Care of anatomy & physiology of women

Question 6

Assessing Families

Family centered care

Answer 6

Structure, parent style, communication, religion, culture, socioeconomic, morbidity, mortality

in delivery room – father, significant other, grandparents
cultural sensitivity
Cultural competence

Question 7

Inspect for Obvious Anomalies

Answer 7

Eyes-Cataract, Retinablastoma
Nose-Choanal Atresia
Mouth-Cleft lip, cleft palate
Tracheoesophageal fistula
Abdominal wall defects
    Omphalocele, Gastroschesis
    Anal malformations
Biliary Atresia
Cardiac Anomalies
Neural tube defects
    Anencephaly
    Encephalocele
    Meningocele
Musculoskeletal defects
   Hip dysplasia
   Talipes varus
   Polydactyl
   Osteogenesis imperfecta
   Amniotic band injuries
GU
   Bladder extrophy
   Intersex
   Hypospadias, Epispadias
   Phimosis
Trisomy 21, 18, 13, Fragile X
Fetal Alcohol Syndrome

Question 8

Retinoblastoma

Answer 8

“Red reflex”
Malignancy of retina
Unilateral or bilateral (25%)
Autosomal dominant gene
		in 40% of children

Chemotherapy, Radiation, Laser photo-coagulation
Surgery -> enucleation

Question 9

Congenital Cataracts
Maternal infections (11)

Answer 9

rubella (the most common cause)
rubeola
chicken pox
cytomegalovirus
herpes simplex
herpes zoster
poliomyelitis
influenza
Epstein-Barr virus
syphilis
toxoplasmosis

tetracycline antibiotics – correlation

EASILY TX

Question 10

Choanal Atresia

Answer 10

Nasal passages are blocked by bone, soft tissue
70% are unilateral
Most are not dx at delivery
If bilateral = respiratory distress

Tx Stents are placed in nares

Question 11

Cleft lip

Integrate nursing interventions (5)

Answer 11

Happens at about 6-8 weeks gestation

Respiratory status
Feeding behaviors
Parent/infant interactions - bonding
Skin integrity, Oral hygiene
Prevention of Infection

Breastfeed? YES
Hard? Yes

Cocaine increases incidence

Question 12

Cleft lip

Treatment

Answer 12

Surgery, based on severity

Modified feeding techniques or devices

Question 13

Feeding Difficulties

ESSR

Answer 13

ESSR
E = Enlarge the nipple
S = Stimulate the suck reflex
S = Swallow fluid appropriately
R = Rest when infant signals with facial expression

Lamb’s nipple with X
Haberman

Question 14

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)
Esophagus ends as...

Answer 14

Esophagus and trachea do not develop as parallel tracts

Esophagus ends as either…
Blind pouch (baby would need a G-tube since may not stretch down to reach stomach)
Connected to trachea by a fistula

Question 15

TEF and EA Clinical Manifestations

5

Answer 15

“The Three C’s”: coughing, choking, cyanosis
Excessive salivation and drooling: frothy mucus
Apnea
Respiratory distress after eating
Abdominal distention

Question 16

TEF and EA – Diagnostic testing and treatment plan

Answer 16

CXR -> radio-opaque or
Pediatric surgeon endoscopy or bronchoscopy

Surgery asap

Question 17

TEF and EA – Nursing Interventions – Prioritize
Airway Management, Aspiration Precautions
Impaired Gas Exchange

Answer 17

Ensure NPO (nothing per os) preoperatively.
Assess Emma’s respiratory status for rate, depth, and ease, and breath sounds q 2-4 hrs and before and after suctioning
Assess Emma’s oxygen saturation level continuously
Elevate Emma’s head of bed (HOB) 30
Administer supplemental oxygen as indicated.
Perform oropharyngeal suctioning as appropriate.
Analyze Emma’s ABG, confer with provider

Question 18

Abdominal Wall Defects
Two Variations of abdominal hernias
Omphalacele

Answer 18

Omphalacele
Intra-abdominal contents herniate through umbilical cord
Covered with peritoneal membrane

Question 19

Abdominal Wall Defects
Two Variations of abdominal hernias
Gastroschisis

Answer 19

Abdominal organs herniate through abdominal wall
Not covered with peritoneal membrane

Stress on respiratory system and may have compromise

Question 20

Anorectal Malformations

Types

Answer 20

Common congenital defects
Minor to complex
Occur in isolation or with other defects

Types
Anal stenosis - narrowing
Anal atresia - absent -> blind pouch or fistulas
Imperforate anus - blind pouch or membrane
Fistula – recto-urethra, recto-vaginal, recto…

Question 21

Biliary Atresia

Answer 21

Absence or constriction of common bile duct
Bile cannot flow from liver into duodenum
Results in
Cholestasis
Fibrosis
Cirrhosis
Death

Question 22

Clinical Manifestations of biliary atresia

Answer 22

Bile backup in liver
   Inflammation, edema, hepatic degeneration
   Malabsorption of fats and vitamins
Jaundice
Dark urine
Acholic stools = WHITE STOOLS
Weight loss
Irritability
Enlarged liver and abdomen

Question 23

CF: Impermeable Epithelial Cells

Answer 23

Excessive mucous production in bronchioles and in pancreas, bile ducts, and small intestine

Cystic fibrosis is a hereditary disorder characterized by lung congestion and infection and malabsorption of nutrients

Instead of producing thin mucous, they produce thick mucous that leads to lung congestion

Question 24

CFTR gene: autosomal recessive

Answer 24

Important Facts:
Both parents contribute the altered gene
Each pregnancy has 25% chance of developing altered gene
Higher incidence in Caucasians and Ashkenazi Jews

Prenatal tests moms are getting blood drawn to test for CF gene 00

Question 25

CF Initial Symptom

Answer 25

meconium ileus -- may be first sign of CF No stool in 24 hours -- obstruction because of thick mucous in intestine gets impacted Steatorrhea -- bulky, frothy, foul-smelling stool

Question 26

Fetal circulation

Answer 26

Ductus arteriosus Foramen ovale Ductus venosus ALL CLOSE

Question 27

Factors associated with CHD Prenatal Genetic

Answer 27

``` Prenatal Maternal insulin-dependent diabetes Maternal rubella Maternal alcoholism Maternal age > 40 yrs ``` ``` Genetic Chromosomal – 50% risk Down Syndrome Sibling with heart defect Parent with CHD Other non-cardiac congenital anomalies ``` Sx. Poor oxygenation, Murmur

Question 28

Diagnosing Heart Anomalies

Answer 28

Echocardiogram | Cardiac catheterization

Question 29

CHD Acyanotic Increased pulmonary blood flow Obstructed blood flow Cyanotic Decreased pulmonary blood flow Mixed blood flow

Answer 29

Acyanotic Increased pulmonary blood flow --> VSD, ASD, PDA, AVC Ventricular septal defect, atrial septal defect, patent ductus arteriosus, atrioventricular canal Obstructed blood flow --> COA, AS Coarctation of aorta, aortic stenosis Cyanotic Decreased pulmonary blood flow --> TOF, PS, T/PA Mixed blood flow --> TGA, HLHS, TAPVR, TA Transposition of great arteries, hypoplastic left heart syndrome,

Question 30

Ventricular Septal Defect

Answer 30

Small or large opening in septum between left and right ventricles Left to right shunting

Question 31

VSD Assessment

Answer 31

Tachypnea, dyspnea Poor growth, reduced fluid intake Frequent respiratory infections Onset of Heart Failure

Question 32

Atrial Septal Defect

Answer 32

Small or large opening in septum between the left and right atria Foramen ovale doesn’t close

Question 33

Patent Ductus Arteriosus

Answer 33

Connection between the aorta and the pulmonary artery Blood flows from the aorta (left side) to the pulmonary artery (right side) increasing blood flow to the lungs

Question 34

Coarctation of the Aorta

Answer 34

Aorta narrows, usually near the ductus arteriosus, obstructing blood flow Ejection click Systolic murmur Persistent hypertension is common – restenosis can occur

Question 35

Transposition of the Great Arteries

Answer 35

Parallel circulation Aorta originates from the right ventricle Pulmonary artery originates from the left ventricle Prostaglandin to maintain PDA

Question 36

Genetics and environment + | Folic acid deficiency can lead to...

Answer 36

Anencephaly Encephalocele Spina Bifida Occulta Spina bifida cystica

Question 37

Head deformities

Answer 37

Microcephaly -- small skull | Anencephaly -- skull does not form over brain

Question 38

Neural tube defects

Answer 38

Encephalocele | Nasoencephalocele

Question 39

Pathophysiology of Neural Tube Defects Prenatal Dx

Answer 39

In first few weeks: Neural Tube fails to close, or Neural Tube splits after closing Prenatal Dx Ultrasound Elevated AFP

Question 40

Spina Bifida (3)

Answer 40

Usually cannot identify which lesion from viewing exterior spinda biffida occulta - Can be fistula or fissure Meningocele Sac contains meninges (membranes) and CSF No spinal cord abnormalities Myelomeningocele Usually in lumbar area but can occur anywhere on spinal column Impact depends on location Infection, lots of compromise Last two Spina Bifida Cystica

Question 41

Impact of neural tube defects L2 S3

Answer 41

Below L2 Partial paralysis of lower extremities Incontinence Below S3 No motor impairment May be incontinent or have some control

Question 42

Nursing Interventions | Pre-op (5) for neural tube defects

Answer 42

``` Pre-Op Cover sac with warm NS sterile dsg Monitor for CSF leakage Prone with knees slightly flexed Assess bowel, bladder function Monitor for signs of infection ``` Family Centered Care Involve parents in care Hold the baby

Question 43

Developmental Dysplasia of Hip | Ortolani’s maneuver -- physical exam test for hip dysplasia

Answer 43

Instability Dislocation Subluxation Acetabular dysplasia Pavlik harness –dynamic splint that allows movement

Question 44

Talipes Varus

Answer 44

aka club foot

Question 45

Polydactyly

Answer 45

extra digits

Question 46

Osteogenesis Imperfecta

Answer 46

Genetic disorder - “brittle bone disease” Autosomal dominant - affecting production of collagen, the major protein of the body’s connective tissue Less than normal or poor collagen leads to weak bones that fracture easy 4 types of OI, mildest may not be dx all until a routine xray discloses multiple fractures

Question 47

Hypospadias and Epispadias

Answer 47

Epispadias “top” of the penis (dorsal) Ends in an opening at the upper aspect of the penis Hypospadias “under” the penis (ventral) A condition in which the opening of the penis is on the underside rather than the tip.

Question 48

Phimosis Bladder Exstrophy

Answer 48

``` Foreskin doesn’t retract Anomaly vs Develop. Delay Tx with cortisone cream Surgical intervention: Circumcision for adults ``` Bladder exstrophy -- protrusion of the urinary bladder through a defect in the abdominal wall Intersex ambiguous genitalia and/or gender chromosomes

Question 49

Down Syndrome Phenotype - observable

Answer 49

Trisomy 21 Advanced maternal age Advanced paternal age Ultrasound, amniocentesis ``` Nuchal fold translucency Epicanthal eye folds Simian crease on palm Flat nose Wide, short neck Hypotonia ```

Question 50

Edwards Syndrome Ultrasound

Answer 50

``` Trisomy 18 90% stillbirth Rare to live beyond first 1 yr Advanced maternal age Advanced paternal age ``` Ultrasound: Microcephaly, small jaw Low set ears Rocker feet Other anomalies: cleft lip/palate, cardiac, meningocele, kidney,

Question 51

Patau Syndrome

Answer 51

Trisomy 13 90% stillbirth Rare to live beyond first 1 yr Multiple anomalies Ultrasound: Microcephaly, sloping forehead Low set ears Rocker feet

Question 52

Fragile X

Answer 52

X chromosome disorder Neural development impaired due to a malfunctioning protein in the gene Female carriers ``` Phenotype - Facial Characteristics Long face Prominent jaw Large ears Strabismus ```

Question 53

Fetal Alcohol Syndrome

Answer 53

Most common cause of intellectual disability ``` Phenotype Small eye opening Flat nasal bridge Short upturned nose Smooth philtrum Thin vermilion ``` Infant Behavior Dysphagia

Question 54

Prenatal Core Measures

Answer 54

Elective delivery Induced deliveries less than 39 weeks gestation Why? There is a higher rate of c/s and neonatal morbidity and mortality when patients are induced when they are less than 39 weeks. Cesarean section Deliveries by c/s Why? C/S are a riskier delivery procedure with a higher rate of maternal and neonatal morbidity and mortality. Antenatal steroids Preterm laboring patients that received antenatal steroids Why? Antenatal steroids reduce the risk and incidence of premature neonatal morbidity and mortality from respiratory distress syndrome. Health-care associated bloodstream infections in newborns Newborns with HCA bloodstream infections Why? High neonatal morbidity and mortality from preventable infections (handwashing, sterile technique). Exclusive breast milk feeding Newborns fed breast milk only from delivery Why? The benefits to newborns from breast milk feeding are significant

Question 55

Amniotic Band Syndrome

Answer 55

Amniotic Band Syndrome occurs when the unborn baby (fetus) becomes entangled in fibrous string-like amniotic bands in the womb, restricting blood flow and affecting the baby’s development. Lose fingers, toes, cleft lip, club feet