Pediatric Case Study

The charge nurse tells you that you will be admitting a 1-hour-old girl, Baby Girl R., with a myelomeningocele that was discovered in utero. You know that the mother will still be at the local medical center recovering from her cesarean delivery.

What is the rational for doing a cesarean delivery for babies with myelomeningocele?

The infant arrives accompanied by her aunt and father. While you are getting vital signs (VS), the father tells you that he has been trying to research myelomeningocele on the internet, but he is still confused, especially about the difference between myelomeningocele and meningocele.

Using lay terms, what would you tell the father about the pathophysiology of myelomeningocele? What is the difference between myelomeningocele and meningocele?
Following your discussion with the family, which of these statements by the father would indicate a need for more teaching? Select all that apply
“My baby’s malformation can also be referred to as spina bifida (SB) cystica”
“My baby will probably not require surgery until she is a year old”
“My baby will need to lie on her stomach in her incubator”
“I need to wash my hands carefully to prevent spread of germs”

Baby Girl R. is in an open warmer. You document the following information

Chart

Admission Data:

Blood pressure 67/33 mm Hg

Pulse 173 beats/min

Respirations 52 breaths/min

Temperature 37.1 C

Sao2 95%s

Weight 3.5 kg

FOC 37 cm

Fontal soft and flat. Pupils 2 cm, brisk reaction, Sleepy, squirms and fusses during pupil check, breath sounds clear; bowel sounds present. Pulses 2+ and capillary refill time less than 3 seconds. Bilateral clubfeet, and no reaction when pulse oximeter is place on right foot. Sac in sacral region covered with sterile gauze that is moistened with saline.

Which of the previous assessment and monitoring data are abnormal for a 1 hour old infant?

Explain the rational for the following orders:

Orders:

Place in prone position

Place PIV with D5 1/3 NS at 15 mL/hr

Administer IV antibiotics as ordered

PT (physical therapy) consult

Open warmer

Orthopedic consult

Place Foley catheter

NPO

Maintain sterile gauze with NS to sac/monitor q1h

Measure FOC (frontal occipital circumference) every shift

The surgeon orders cefazolin sodium (Ancef) 140 mg on call to the OR. You add 10 mL of sterile water to the 1 gm vial for concentration of 100/mg/mL. Calculate how many milliliters you will draw up for this dose.

The next day in report you hear that Baby Girl R. did will overnight. She goes to surgery at 0815. Later, the post-anesthesia care unit (PACU) nurse tells you that Baby Girl R. is ready to return to your unit. When she arrives, you and the NAP start putting on the monitors. Mr. R. is present, and he asks you to give the baby some pain medication. The open warmer starts alarming because the patients’ skin temperature is reading 35° C. You look down at her to see whether the temperature probe has fallen off. You see that it is still on, but you also notice that the suture from surgery is no longer intact. Then the oxygen monitor reads 71% saturated with an accurate waveform, and the pulse oximeter probe is correctly placed on the patient. The patient’s respiratory rate is 25 breaths/min and the heart rate is 102 beats/min.

Which of the issues should you address first? Give rationale

Baby Girl r. stabilizes. Her temperature is 36.7° C per skin probe. Respiratory rate and heart rate improve and her Sao2 is 98% on ¼ LPM oxygen per nasal cannula. The surgeon is at the bedside and patient returns to the OR for revision of Incision.

Two days later, you are caring for Baby Girl R.at night. In report, you hear that the parents really want to hold their baby, but they have not yet because they are afraid of causing the suture to open again. They are currently at the bedside, and the infant is due for a feeding.

How can you help the parents become comfortable with holding their baby?
When you take the bottle in to the patient’s room, you notice a growth chart next to the bed. Tracking the patient’s frontal occipital circumference (FOC) that is measured at least once per shift. Baby Girl R.’s FOC has increased to 38.5 cm. Using the appropriate CDC growth chart (http://www.cdc.gov/growthcharts/data/set2/chart%2010.pdf) is the following statement true or false?

The FOC is close to the 95% and can be monitored less frequently because this is normal finding.

Case Study Outcome

Baby Girl R. is followed closely in the Level 2 nursery. She stabilizes and is able to be discharged to home in 2 weeks with close multidisciplinary follow-up