MCN Exam 3 Study Guide – Complete Colin MacKenzie

The Newborn Transition

1. Terminology:
a. Perinatal Period: from the 28th week of gestation until the 7th day after birth
b. Neonatal Period: the first 28 days of life
2. Respiratory Adaptations:

a. Signs that the baby is in respiratory distress when it is born:

i. Color changes (dusky, purple)
ii. Respiratory effort (low or none present)
iii. Respiratory rate (low or none present)

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b. Neonates born via c-section do not get the “squeeze” from the birth canal that
helps compress the baby’s body and force that first breath
i. Retractions
3. Cardiovascular Adaptations:
a. Fetal Circulation
i. Placenta provides oxygen and nutrients, removes waste
ii. Circulation depends on fetal structures
1. Ductus Arteriosus
a. Shunts blood from pulmonary artery to aorta
2. Foramen Ovale
a. Shunts blood from right to left atrium (way to bypass the
lungs)
3. Ductus Venosus
a. Bypasses hepatic system to vena cava
iii. All 3 should close when the fetus is born, and lungs open
iv. Clamping the umbilical cord at birth eliminates the placenta as a reservoir
for blood
v. Steps for this to happen:
1. Oxygen gets into the lungs
a. Decreases pulmonary vascular resistance
b. Increases pulmonary blood flow to the lungs
c. Increases pressure to left atrium
i. Closes the foramen ovale
2. Cord is cut which decreases blood flow to the ductus venosus,
which closes it off
a. Will become a ligament once this occurs
3. Blood starts flowing in a “normal” fashion
a. Blood comes out of the aorta which increases pressure
and changes direction of it
b. Change in pressure causes the ductus arteriosus to close
and become a ligament
b. Transient functional cardiac murmurs may be heard during the neonatal period
as a result of the changes to the cardiovascular system at birth

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4. Body Temperature Regulation:

a. Correlate hypothermia with hypoglycemia and hypoxia

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5. Heat Loss in the Newborn:

a. Evaporation:
i. Dry them immediately after birth (don’t keep them wrapped in the same
blanket)
ii. Keep them dry
b. Conduction:
i. Do not place the baby on cold objects without some sort of barrier
between them (i.e. a blanket)
ii. Warm your hands before touching the baby
iii. Warm any instruments that you may be using to assess the baby (i.e.
stethoscope)
c. Convection:
i. Keep baby away from fans and drafts
d. Radiation:
i. Keep the baby away from cold surfaces (i.e. a window in the wintertime)
ii. Put a knit cap on the baby’s head
6. Hepatic Function:
a. Most functions of the liver are not fully active until 3 months of age
b. Major functions of liver:
i. Blood coagulation

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ii. Conjugation of bilirubin

iii. Storage of fat-soluble vitamins (A, D, E, K)
iv. Carbohydrate metabolism
v. Iron storage
vi. Detoxification

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7. Gastrointestinal Adaptations:

8. Renal Changes:

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a. Immature kidneys
i. Lower tolerance to fluid imbalance
ii. Fluid losses occur quickly
1. Caused by not taking in a lot of fluid, insensible water losses
(increased RR and metabolism), decreased ability to reabsorb
sodium
iii. Body mass = 75% water!
iv. Dehydration is a major issue for babies
b. Urine output
i. Normal output: >1 mL/kg/hr.
1. 6-8 wet diapers/day (after first few days)
ii. May contain pink uric acid crystals in first voids
iii. Decreased GFR (decreased specific gravity)
1. This means the baby can become overloaded with fluid easily
(because they can’t get rid of it quickly)
2. Be mindful of how much you’re giving them via IV
9. Immune Adaptations:

10. Integumentary Adaptations:

a. Skin - one of the largest newborn organs
i. Provides protective barrier to pathogens
ii. Low fat and high-water content compared to adults
iii. Limits loss of water
iv. Assists with thermoregulation

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v. Protects from physical trauma

b. Fragile with high risk for tearing
i. Avoid putting band-aids or tape on them (could pull off the skin)
ii. Keep skin dry
iii. Reduce friction issues
c. May look dry, and peel after birth
11. Neurologic Adaptations:
a. Development follows a cephalocaudal (head to toe) and proximal-distal (center
to periphery) pattern
b. Newborn has acute sensory capabilities:
i. Hearing: well developed at birth, baby will turn towards sound
ii. Taste: Distinguishes sweet & sour at 72 hours old
iii. Smell: Distinguishes mother’s breast milk
iv. Touch: Sensitive to pain, responds to tactile stimuli
v. Vision: Incomplete at birth, initially focuses at 8-15 inches, see in black
and white
1. Hold the baby in your arm and keep your face within this distance
2. Binocularity begins to develop at 6 weeks and is established at 4
months
3. Toys should be black and white at first
4. Color vision, distance, and tracking are not fully complete until 7
months
c. Reflexes – important indicators of neuro function
i. Absence, persistence, or reappearance could be a problem with brain
functioning (pathology)
ii. Earlier identification and early intervention and less complications
12. Behavioral Patterns for the Newborn:

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13. Behavioral Responses:

a. Neurobehavioral response: how the newborn reacts to the world around them;
should be predictable
b. Expected behaviors:
i. Orientation – response of newborns to stimuli, alertness
ii. Habituation – responds to and then blocks out stimuli
iii. Motor maturity – controls and coordinates movement (not purposeful
movement)
iv. Self-quieting ability – “consolability,” teach parents about how to do this
(i.e. swaddling, shushing them, swinging, sucking on things)
v. Social behaviors – “cuddling” and positive responses to interaction

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Nursing Care of the Newborn

1. Initial Newborn Assessment:

2. Signs that might indicate a problem:

a. Nasal flaring
b. Chest retractions
c. Grunting on exhalation
d. Labored breathing
e. Generalized cyanosis
f. Abnormal breath sounds (rhonchi, crackles, wheezing, stridor)
g. Tachypnea (> 60 breaths/min)
h. Bradypnea (< 30 breaths/min)
i. Flaccid body posture
j. Pallor
k. Apneic episodes
l. Abnormal heart rates
m. Abnormal newborn size (SGA or LGA)
3. Immediate Interventions:
a. Maintain airway patency
i. Suction with bulb syringe, mouth first then nose
1. Keep bulb syringe with the baby at all times

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b. Evidence supports just using a towel for term infants

c. Ensure proper identification
i. Mother/newborn/significant other ID bracelets (2 on newborn)
ii. Same identification number on all
iii. Security band
4. Newborn Measurements:

5. Newborn Vital Signs:

a. Vital Signs: every 30 minutes until stable for 2 hours
i. Temperature: 97.7˚-99.5˚ F (36.5˚-37.5˚ C)
ii. Pulse: 110-160 bpm
iii. Respirations: 30-60 rpm
6. Maintain thermoregulation:
a. Stabilize newborn temp: 97.7-99.5 F
i. Dry infant immediately
ii. Skin to skin with Mom
iii. Use radiant warmer
iv. Wrap in warmed blankets
b. Neutral thermal environment (NTE)
c. Regulate environmental temperature
i. Warm room temperature
ii. Eliminate drafts or ceiling fans
7. Administer medications (Drug Guide 18.1, p. 630):
a. Vitamin K – necessary to synthesize clotting factors
i. Administer within 1-2 hrs. after birth
ii. IM injection
b. Erythromycin ophthalmic ointment – to prevent ophthalmia neonatorum
conjunctivitis
i. Prophylactic for chlamydia and gonorrhea
1. Can cause blindness in babies
ii. If membranes have ruptured, do this for vaginal and c-section births

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iii. Be alert for chemical conjunctivitis for 1-2 days

8. Gestational Age Assessment:
9. Dubowitz/Ballard Scoring Tool (Figure 18.3, p. 627)
a. Performed within 24 hours after birth, if stable
b. 2 components of assessment:
i. Physical Maturity
1. Skin texture
2. Lanugo – soft downy hair
3. Plantar creases
4. Breast tissue
5. Eye and ears
6. Genitals
ii. Neuromuscular Maturity
1. Posture – ranging from fully extended to fully flexed
2. Square Window (wrist) – bending the newborns hand at the wrist
3. Arm Recoil – newborns arm is passively extended and
spontaneously returns to flexion
4. Popliteal Angle – degree of the angle to which the newborn’s
knees can extend
5. Scarf Sign – crossing the newborns arm over the chest
6. Heel to Ear – how far the newborn’s heels reach to their ears
10. Head to Toe Assessment:
a. Skin
b. Head
i. Head circumference may need to be remeasured later if the shape of the
head was altered due to delivery
c. Muscle tone & activity
d. Chest, Abdomen
i. Head and chest circumferences are usually equal by about 1 year
e. Reflexes
f. Safety
g. Parental interaction and teaching
11. Skin Variations:
a. Vernix Caseosa – thick white substance that protects the skin
b. Acrocyanosis – cyanosis of hands and/or feet
i. Not uncommon; sign that the baby is still acclimating to life outside the
womb
ii. CONCERN: central cyanosis by the face or mouth
c. Milia – unopened sebaceous glands on the nose; disappear within 2-4 weeks (not
a problem)
d. Epstein’s Pearls – milia formed in the mouth (not a problem)
e. Stork Bites/Salmon Patches – superficial vascular areas on the nape of the neck,
eyelids, or between the eyes; fade by 1 year
f. Erythema Toxicum – benign popular-pustular rash

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g. Mongolian Spots – bluish spots on lower back and/or buttocks

h. Harlequin Sign (“clown suit”) – dilation of blood vessels on one side of the body
(not a problem)
i. Nevus Vasculosus (strawberry mark/hemangioma) – may darken, but should
disappear by age 3
j. Nevus Flammeus (port wine stain) – usually on face or head area; permanent;
best if treated by 1 year of age
12. Head Variations:
a. Fontanels – soft membranous gaps between skull bones
b. Sutures – fibrous joints occurring only in the skull
c. Molding – elongated head shape to accommodate birth canal
d. Cephalhematoma – localized effusion of blood beneath the periosteum of the
skull
i. Does NOT cross the suture lines
ii. Result of a difficult birth
iii. Can contribute to jaundice
iv. Will go away but it can take awhile for it to do so (weeks or even months)
e. Caput Succedaneum – localized serous (non-blood), soft tissue swelling
i. Not localized to one side
ii. Crosses the suture lines
iii. Since it is serous fluid, not worried about jaundice
iv. Commonly observed after prolonged labor
v. Tends to resolve within 3-5 days
13. Reflexes:
a. Except for “gag and cough reflexes” these tend to disappear by 1 year of age
i. Sucking
ii. Rooting
iii. Moro (startle reflex)
iv. Stepping
v. Babinski
vi. Grasp (palmer & plantar)
vii. Tonic neck (fencing reflex)
viii. Truncal incurvation reflex (Galant reflex)
ix. Gag and cough reflexes
14. Newborn Immunizations:
a. Hepatitis B Vaccine (IM)
i. CDC recommends all neonates be vaccinated with hepatitis B vaccine
within 12 hours after birth
ii. If mother HBsAg neg:
1. May defer to 1-2-month pediatrician visit
iii. If mother HBsAg pos:
1. Hep B dose 1 and HBIG (Hepatitis B immunoglobulin) within 12
hours of birth
2. Both given before breastfeeding initiated

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15. Newborn Screening Tests:

a. Genetic and Inborn Errors Of Metabolism
i. Tests vary by state (Florida requires screening for 53 disorders)
ii. Common tests: PKU, congenital hypothyroidism, galactosemia, SSA (p.
657, Table 18.5)
iii. Done at least 24 hours after first feeding
b. Hearing Screening
i. All babies before discharge
ii. Hearing loss most common birth disorder in US
c. CCHD (Critical Congenital Heart Defects)
i. Pulse-ox readings of right hand and either foot
ii. If there is a discrepancy between the hand and foot numbers (should be
at 100%), need a cardiologist consult to make sure there are no defects
or problems
iii. Completed after 24 hours, screens for 7 Complex Congenital Heart
Defects
16. Discharge Planning – Education:

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Newborn Complications #1
1. Factors Affecting Fetal Development:
1. Maternal: HTN, smoking, diabetes, weight gain, substance abuse
2. Placental: calcification (aging) of the placenta, size (insufficiency), previa/abruption
3. Fetal: sex (males larger), multiple gestations, anomalies/chromosomal defects, fetal
infection
2. Variations in Birthweight and Gestational Age:
1. Gestational age at birth is inversely related to the developmental challenges the
neonate will face (closer to term, the less risks they will face)
2. Variations in either can increase neonatal risk factors
3. Nurses must know how to identify newborns at risk, based on these variations
4. Classification methods:
1. Birthweight
2. Birthweight and gestational age
3. Gestational age
3. Birthweight Variations:
1. By Birthweight and Gestational Age
1. AGA (appropriate for gestational age)
2. SGA (small for gestational age)
3. LGA (large for gestational age)
2. By Birthweight
1. Low birthweight
2. Very low birthweight
3. Extremely low birthweight
4. Classification by Birthweight and Gestational Age:

5. Small for Gestational Age (SGA):

1. <10% on growth chart for age
2. Risk factors:

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1. Maternal: smoking/drug use, genetics, multiple gestations, hypertension,

maternal illness
2. Gestational hypertension and/or diabetes
3. Placental factors (small placenta, placenta previa, decreased placental perfusion)
4. Fetal congenital infections (rubella, toxoplasmosis)
5. Small cord → poor nutrients provided (O2) → polycythemia →
hyperbilirubinemia
6. Poor fat reserves (brown fat) → hypothermia → hypoglycemia
3. Assessment findings:
1. Disproportionately large head
2. Thin extremities and trunk
3. Reduced subcutaneous fat stores
4. Thin umbilical cord
1. Less blood supply, oxygen, and nutrient delivery
5. Loose, dry skin
6. Drawn abdomen rather than well-rounded
7. Respiratory distress and hypoxia
8. Hypoglycemia
4. Lab Tests:
1. CBC will show polycythemia resulting from fetal hypoxia and intrauterine stress
2. Chest x-ray to rule out meconium aspiration syndrome
5. Identify Fetal Growth Restriction (FGR)
1. Pathologic counterpart of SGA
2. Can result from aneuploidy, congenital malformations, infections, or
uteroplacental insufficiency
3. At risk for lifelong developmental deficits
6. SGA - Nursing Management:
1. Weight is generally 5 lbs., 8 oz or less
2. Hypothermia
1. Provide a neutral thermal environment for the newborn (isolette or radiant heat
warmer)
3. Hypoglycemia
1. Initiate early feedings (an SGA will require more frequent feedings)
2. Administer parenteral nutrition if needed
4. Polycythemia (making more RBCs to get more oxygen to the fetus)
/Hyperbilirubinemia
1. Hematocrit >65%
2. Hemoglobin > 20 gm/dL
1. Polycythemia:
1. Blood can get thicker, more sludge-like
2. Possible signs and symptoms:
1. Poor perfusion, red skin, respiratory distress, higher risk for jaundice
3. Treatment: dilute the blood (possible IV fluids)

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5. Provide parental education

6. On-going growth follow-up
7. Large for Gestational Age (LGA):
1. Weight is generally > 9 lbs.
2. Risk factors:
1. Maternal diabetes mellitus, prolonged pregnancy, previous LGA baby, maternal
obesity
2. Mother with DM → fetus has insulin stores → hypoglycemia (not enough
carbohydrates to bond with insulin)
3. Assessment findings:
1. Large body, appears plump, full faced
2. Head circumference/body length at upper limits
3. Manifestations of hypoxia including tachypnea, retractions, cyanosis, nasal
flaring, and grunting
4. Birth trauma
5. Tremors from hypocalcemia
6. Hypoglycemia
7. Respiratory distress from immature lungs or meconium aspiration
4. Nursing Concerns:
1. Traumatic birth injuries
1. Shoulder dystocia, clavicle fractures, difficulty getting thru the birth canal
2. Hypoglycemia
3. Polycythemia / hyperbilirubinemia
8. Common Neonatal Problems: Hypoglycemia
1. Blood glucose level <40 mg/dL
2. Risk factors:
1. Maternal DM, prematurity, inadequate calorie intake, sepsis, asphyxia,
hypothermia, LGA or SGA neonate
3. Assessment:
1. Listlessness/lethargy
2. Weak cry, poor feeding
3. Tremors, irritability
4. Flaccid muscle tone
5. Apnea
6. Cyanosis
7. Diaphoresis
8. Hypotonia
9. HYPOTHERMIA!
4. Treatment:
1. Early recognition and intervention
2. Frequent glucose monitoring
3. Immediate and frequent feedings, if not…
1. IV glucose (D5W or D10W) for severe condition
5. Prevention:

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1. Early initiation of feedings

2. Frequent assessment of high-risk newborns
3. NTE - thermoregulation
9. Common Neonatal Problems: Hyperbilirubinemia (Jaundice)
1. Most common reason for hospital readmission
2. Results from imbalance in rate of bilirubin production and elimination (immature
newborn hepatic system)
3. Essential data: age of newborn (in hours) to determine rate of progression of
condition, cause, and treatment
1. Physiologic > 24 hours
2. Pathologic < 24 hours
3. Significant jaundice in the newborn less than 24 hours of age should be
immediately reported to the provider, as it may indicate a pathologic process
4. Bilirubin is a byproduct of RBC hemolysis
5. Bilirubin has 2 forms: unconjugated and conjugated
1. Unconjugated: fat soluble, toxic to body tissues, unable to be excreted
2. Conjugated: transformed by liver, water soluble, non-toxic, excreted in urine &
stool
6. Newborn is at high risk for jaundice:
1. Immature liver unable to keep up with bilirubin production
2. Fetal RBCs – shorter lifespan → faster break-down
3. RBCs have an even shorter lifespan in premature babies
4. Delay in meconium excretion through bowel
10. Types of Hyperbilirubinemia (Jaundice):
1. 2 types – physiologic and pathologic
1. Physiologic (common, milder):
1. Occurs in 60% of term & 80% preterm newborns
2. Occurs 1-7 days after birth
3. Caused by shortened RBC life & immature liver
4. Levels usually peak at 10mg/dL then decline rapidly
5. May result from one or more of the following:
1. Increased bilirubin load because of relative polycythemia
2. Shortened RBC lifespan
3. Immature hepatic uptake and conjugation process
4. Increased enterohepatic circulation
2. Pathologic (more severe):
1. Occurs in first 24 hours (level rises more than 5 mg/dL in the 1st day is a major
warning sign)
1. More than likely due to an Rh incompatibility
2. Caused by severe polycythemia, blood incompatibilities (Rh or ABO), or
systemic acidosis
3. May reach toxic bilirubin level > 17mg/dL
4. Kernicterus → Encephalopathy (brain damage)
1. Signs and Symptoms of kernicterus:

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1. Very yellowish skin

2. Lethargy
3. Hypotonic
4. Poor feeding
5. Decreased activity
6. High-pitched cry
7. Temperature instability
11. Physiologic Jaundice:
1. Assessment:
1. Assess skin, sclera, body fluids for yellow color
2. Labs: polycythemia, Rh incompatibility, bilirubin, Coombs test (hemolytic disease
of the newborn; antibodies that attack RBCs), maternal and fetal blood types
(checking for incompatibilities)
2. Treatment:
1. Promote early and frequent breast-feeding (8 to 12 feedings per day)
2. Monitor serial bilirubin levels
3. Phototherapy
1. Phototherapy care:
1. Eye shield
2. NTE – frequent temperature monitoring
3. Strict I&O – daily weight – hydration assessment
4. Monitor stool frequency and appearance
5. Positioning (supine) to maximize skin exposure
6. Meticulous skin care – no lotions
7. Parental support and education
12. Pathologic Jaundice- Hemolytic Disease of the newborn (HDN):
1. First 24 hours
2. Rh incompatibility (Isoimmunization):
1. Mother is Rh - & baby is Rh +
2. Mother’s anti-Rh antibodies (initially IgM) do not cross placenta - repeat
encounter will produce IgG antibodies that do cross
3. Effects subsequent pregnancies
3. ABO incompatibility:
1. Mother is type O & baby is A, B, or AB
2. Mother’s anti-A & anti-B antibodies (IgG) attack baby’s RBCs by crossing placenta
3. Less serious reaction than Rh incompatibility
4. Management
1. Ensure adequate hydration
2. Institute early feedings if possible
3. Phototherapy
4. Parental education
5. Exchange transfusion
1. Used only as a 2nd line of therapy after phototherapy has failed to produce
any results

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2. Removes the newborn’s blood and replaces it with nonhemolyzed RBCs from
a donor
1. Monitor the newborns cardiovascular system as serious complications can
arise
6. Counseling for future pregnancies
13. Newborn Infections:
1. Increased susceptibility, immature immune systems
2. Major cause of newborn death (sepsis)
3. Diagnosis is challenging
1. Presenting symptoms are many and nonspecific (i.e. poor feeding, breathing
difficulty, apneas, bradycardia, elevated temperature)
2. Early signs of sepsis in neonates are very subtle
4. Signs and Symptoms:
1. Hypothermia, due to inability to regulate temperature
2. Pallor or duskiness
3. Hypotonia
4. Jaundice
5. Poor weight gain
6. Respiratory distress
7. Irritability
8. Hypoglycemia
9. Seizures
5. Neonatal Sepsis:
1. Presence of bacterial, fungal, or viral microorganisms (or toxins) in blood or other
tissues - most common Group B Strep
2. Presents as: septicemia, pneumonia, meningitis
6. TORCH infections - group of infections acquired perinatally (infection direct from the
mother)
1. Toxoplasmosis
1. Infected cat feces (mom should not be cleaning the kitty litter)
2. Other (Gonorrhea, Syphilis, HIV, Chlamydia)
3. Rubella
1. Often leads to miscarriages if mom is exposed to this
4. Cytomegalovirus
1. Uterine growth retardation
2. Often results in stillbirths or miscarriages
5. Herpes Simplex Virus
14. Newborn Infections – Nursing Management:
1. Early recognition and treatment
1. Culture samples taken until the infection clears
2. Antibiotic therapy (usually started before the infecting pathogen is identified) –
monitor response
1. 7-21 days for positive cultures
2. 72 hours until negative cultures

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3. Supportive care: oxygen PRN, pain control

4. Promote hydration – po/IV fluids
5. Prevention: handwashing, aseptic wound care, frequent monitoring of invasive
catheter sites, identifying risk factors, family education
6. Monitor VS changes and observe for subtle signs of infection
7. Monitor for signs of organ system dysfunction:
1. Cardiovascular – tachycardia and hypotension
2. Respiratory – tachypnea and respiratory distress
3. Renal – oliguria or anuria (failure of the kidneys to produce urine)
4. System compromise – abnormal blood values
15. Transient Tachypnea of the Newborn (TTN):
1. Self-limiting respiratory disorder
1. Mild respiratory distress
2. Cause: retention of fluid in lungs or transient pulmonary edema
3. Fluid in fetal lung eliminated slowly or incompletely
4. Occurs within a few hours of birth, resolves by 72 hours
2. Risk factors: cesarean birth, prolonged labor, male, maternal asthma, fetal
macrosomia, maternal meds
3. Assessment: retractions, expiratory grunting, cyanosis
4. Diagnostics: chest x-ray
5. Treatment (supportive):
1. Supplemental oxygen
2. Frequent assessment
3. Thermal regulation and NTE
4. IV fluids or gavage feedings until stable respiratory status

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Newborn Complications #2
1. Preterm Newborns:
a. Born before completion of 37 weeks (< 38 weeks)
b. Prematurity is the 2nd leading cause of newborn death
2. Effects of Prematurity:
a. Respiratory → Chronic Lung disease; O2 use can cause retinopathy of
prematurity
i. Other problems include:
1. Surfactant deficiency → development of respiratory distress
syndrome
2. Unstable chest wall → atelectasis
3. Smaller respiratory passages → increased r/f obstruction
4. Inability to clear fluid from the passages → transient tachypnea
b. Cardiovascular → persistent fetal circulation (insufficient O2 levels secondary to
perinatal asphyxia); anemia
c. Gastrointestinal - Uncoordinated suck, swallow
i. Shunting of blood to vital organs; NEC (necrotizing enterocolitis)
d. Renal → decreased GFR
e. Immune → IgG deficiency (crosses the placental barrier at 34-37 weeks);
infection, septicemia
f. Central Nervous System:
i. Mental/motor/developmental delays
ii. Intraventricular hemorrhage (IVH)
3. Preterm Newborn Assessment:
a. Ballard Scale – determining the maturity level of neonates
b. Physical characteristics:
i. Skin – transparent, minimal subcutaneous fat; plentiful vernix caseosa
ii. Lanugo – sparse
iii. Plantar creases – absent, to few, on soles & palms
iv. Breast tissue – not developed
v. Eyelids fused, poorly formed ear pinna
vi. Genitals – undescended testes/clitoris prominent
c. Neuromuscular characteristics:
i. Poor muscle tone and flexion
ii. Increased flexibility – minimal resistance when performing
neuromuscular assessments
d. General:
i. Scrawny appearance
ii. Head disproportionately larger than chest
4. Nursing Care Plan 23.1, PP. 899-900
a. Promote oxygenation
b. Promote thermoregulation

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c. Promote optimal nutrition and fluid balance

d. Prevent infection
e. Provide appropriate stimulation
f. Manage pain
g. Promote parental coping
5. Routine NICU Care:
a. Continuous cardiac and respiratory monitoring
b. Neutral thermal environment
c. Low stimulation – Isolettes, cluster care
d. Fluid management, I&O, daily weights
e. Nutritional support; glucose level maintenance
f. Infection prevention:
i. Handwashing
ii. Screening visitors
g. Prone position (increases resp system [specifically the lower lobes], decreases
stress)
h. Parental education and participation in care
6. Preterm Nursing Management Priorities:
a. Promote oxygenation
i. Identify asphyxia - prepare for resuscitation
1. Remember your ABCDs (airway, breathing, circulation, and drugs)
ii. Administer oxygen (judiciously) to maintain p/ox from high-80s to mid-
90s
iii. Monitor respiratory status and airway patency
1. Hypoxia: too little O2 in the cells of the body
a. S/S: HR ↓, cyanosis develops, temperature ↓, BP ↓,
respirations are altered (apnea, tachypnea, retractions,
grunting, nasal flaring), hypotonicity, and eventually
unresponsiveness
iv. Minimize stimulation (handle as little as possible) and cluster all care
v. Provide energy through calories via IV or gavage or continuous tube
feedings to prevent hypoglycemia
vi. Monitor HR
vii. Suction as needed
viii. Maintain a neutral thermal environment
ix. Administer medication (surfactant)
b. Maintain thermoregulation
i. Signs and Symptoms of a preterm newborn having difficulty with
thermoregulation:
1. Skin feels cool to cold to the touch
2. Hands, feet, and tongue may appear cyanotic
3. Shallow or slow respirations
4. Signs of respiratory distress may be present
5. Lethargy

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6. Hypotonicity
7. Feeds poorly
8. Feeble cry
9. Hypoglycemia
ii. Remember 4 mechanisms for heat transfer/loss
1. Convection
2. Conduction
3. Radiation
4. Evaporation
iii. Radiant warmer, isolette, kangaroo care (if stable)
1. Kangaroo care benefits:
a. Maintains physiological stability
b. Helps to increase immunity
c. Optimizes breastfeeding
d. Facilitates parent-infant bonding
iv. Assess temperature every hour until stable
v. Observe for signs of cold stress
1. Respiratory distress, central cyanosis, hypoglycemia, lethargy,
weak cry, abdominal distention, apnea, bradycardia, acidosis
vi. Monitor for hypothermia and hyperthermia
c. Promote nutrition and fluid balance
i. Monitor daily weight, strict I&O/calorie count
ii. Encourage breast feeding/use of maternal breast milk
1. Baby may not be given breastmilk yet, but mom can pump, and
we can store the milk until it is ready to do so (past 34 weeks)
iii. Continually assess for enteral feeding intolerance
1. Measure abdominal girth
2. Auscultate bowel sounds
3. Measure residuals before next tube feeding
iv. Assess fluid status
1. Neat tip: palpate the fontanels
a. Sunken fontanels suggest dehydration
b. Bulging fontanels suggest overhydration
d. Prevent infection
i. Monitor changes in VS
1. First sign of infection is unstable temp in a premature neonate
2. Tachycardia
3. Tachypnea
ii. Assess O2 saturation levels
iii. Assess feeding tolerance (not wanting to feed is an early sign of infection)
iv. Protect skin
v. Standard precautions
vi. Screen visitors
e. Provide appropriate stimulation

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i. Rocking, swaddling, sucking, massage, holding

ii. Promote growth and development
iii. Alter NICU environment, cluster care
f. Manage pain
i. Differentiate pain from agitation by observing for changes in VS, behavior,
facial expression, and body temperature
ii. Suspect pain if any of the following are exhibited:
1. Sudden high-pitched cry
2. Facial grimace with furrowing of the brow and quivering chin
3. Increased muscle tone
4. Oxygen desaturation
5. ↑ HR
6. Body posturing (i.e. squirming, kicking, arching)
7. Limb withdrawal
8. Thrashing movements
9. ↑ BP, pulse, and respirations
iii. Assess response to both pharmacologic and nonpharmacologic pain
therapy within 30 minutes of administration
g. Promote parental coping
i. Validate feelings
ii. Encourage frequent visits
iii. Identify family and community resources
7. Prepare for Discharge (p. 895, Box 23.6):
a. Provide parental education
i. Discuss early signs of complications and what to do if they occur
ii. Demonstrate techniques for special care procedures such as dressings,
ostomy care, etc.
b. Teach infant CPR and emergency care
c. Assess parents emotional stability and coping status
d. Develop appropriate home care environment
e. Establish a medical home and referrals
f. Initiate primary care routine
g. Celebrate progress and milestones!
i. Baby will more than likely be behind for a while, so be aware of that
ii. Still, celebrate whenever they do reach a milestone and progress
8. Dealing with Perinatal Loss:
a. Defined as: loss during, or a neonatal death up to 1 month of age
b. Assisting parents to cope (p. 898, Table 23.2)
i. Convey concern and acknowledge parental loss
ii. Use active listening
iii. Give parents a sense of control
iv. Provide privacy as needed
v. Assist parents to make memories
vi. Photos, lock of hair, blanket the baby used, etc.

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vii. Respect and incorporate cultural interventions

viii. Help family with grieving process
c. Supporting the family afterwards
9. Respiratory Distress Syndrome (RDS):
a. Disorder from lung immaturity due to lack of surfactant
b. Risk factors: preterm, maternal Diabetes Mellitus (high levels of insulin inhibit
surfactant production), perinatal asphyxia, cold stress
c. Assessment: Grunting, nasal flaring, chest wall retractions, seesaw respirations,
increasing atelectasis, tachypnea, and cyanosis
d. Treatment: supportive
i. Mechanical ventilation if needed
1. PEEP ventilation
a. Used in conjunction with mechanical ventilation
b. Pressure applied by the ventilator at the end of each
breath to ensure the alveoli are not so prone to collapse
c. Increases surface area for gas exchange
2. See the following website for more info on PEEP:
[Link]
peep-positive-end-expiratory-pressure/
ii. CPAP
iii. Administration of exogenous surfactant therapy
1. The earlier it is administered, the better the effect on gas
exchange
e. Management:
i. Continuously monitor the cardiopulmonary status of the infant
ii. Monitor O2 saturation levels
iii. Closely monitor VS, acid-base status, and ABGs
1. Administer sodium bicarbonate or acetate to correct metabolic
acidosis
iv. Provide fluids or vasopressors to prevent or treat hypotension
v. Test blood glucose levels for hypoglycemia
vi. Cluster care
vii. Place the newborn in a prone position to optimize respiratory status and
reduce stress
viii. Assess LOC to identify intraventricular hemorrhage
ix. Maintain a neutral thermal environment
x. Maintain adequate hydration and calories
f. Prevention: single dose betamethasone
10. Effects of Mechanical Ventilation:

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11. Term Newborns:

a. 38-42 weeks
b. Less morbidity and mortality
c. Best outcomes
d. Best ability to deal with stressors
e. Still require much education
f. Adaptation of family
12. Postterm Newborns:
a. At or beyond 42 weeks
b. Risk factor: prior post-term infant
c. Placental issues occur:
i. Placenta and umbilical cord start to calcify over time
ii. Decreased oxygen and nutrient supply
iii. Wasting of fetus due to using stored nutrients
iv. Placenta is old/cord compression → poor nutrients provided →
polycythemia → hyperbilirubinemia
13. Postterm Newborn Assessment:
a. Ballard Scale – common physical characteristics
i. Skin - dry, cracked, peeling, wrinkled
ii. Lanugo – absent, minimal vernix caseosa
iii. Plantar creases - cover the entire soles of feet
iv. Breast tissue – measurable
v. Eyes – fully developed, ears firm and stand away from head
vi. Genitals – creases on scrotum, descended testis, labia majora covers labia
minora

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vii. Neuromuscular characteristics: increased flexion and resistance to range

of motion; less flexibility
viii. General – abundant hair on scalp, thin umbilical cord, meconium-stained
skin/nails; longer nails
14. Postterm Nursing Management Priorities:
a. Anticipate newborn resuscitation – check respirations, ABGs
i. Perinatal asphyxia – caused by placental aging or oligohydramnios that
leads to cord compression
b. Monitor blood glucose levels
i. Hypoglycemia – caused by acute episodes of hypoxia related to cord
compression which exhausts carbohydrate reserves
ii. IV D10W and/or early initiation of feedings will help stabilize BG levels
c. Prevent hypothermia
i. Caused by loss of subcutaneous fat
d. Screen for polycythemia (increase in RBCs to compensate for a reduced oxygen
environment) & hyperbilirubinemia (due to RBC destruction)
i. Providing adequate hydrations helps reduce the viscosity of the newborns
blood to prevent thrombosis
15. Meconium Aspiration Syndrome:
a. Inhalation of meconium-filled amniotic fluid
b. Risk Factors:
i. Post-term pregnancy, maternal DM, prolonged labor; breech
presentation, forceps or vacuum-assisted births, maternal smoking or
drug abuse, maternal infection/chorioamnionitis, maternal HTN, fetal
growth restriction, oligohydramnios, prolapsed cord, acute or chronic
placental insufficiency
c. Assessment:
i. Assess amniotic fluid for staining upon rupturing of membranes (if
possible)
ii. After birth, inspect the umbilical cord and baby for yellowish-green
staining
iii. ABGs will indicate metabolic acidosis
iv. Direct visualization of the vocal cords for meconium staining is needed to
confirm the presence of meconium below the larynx
d. Signs and Symptoms:
i. Barrel-shaped chest (similar to COPD), tachypnea, respiratory distress,
grunting, cyanosis
ii. Uneven pulmonary ventilation (hyperinflation in some areas and
atelectasis in others)
1. This leads to poor perfusion → hypoxemia
iii. Coarse crackles and rhonchi on auscultation of the lungs
e. Treatment:
i. Focus is on adequate tissue perfusion, minimizing O2 demand and energy
expenditure

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ii. Suctioning may be needed, but should be limited to reduce

overstimulation
iii. Maintain a neutral thermal environment
iv. Oxygen therapy via nasal cannula or positive-pressure ventilation
v. Monitor O2 saturation levels
vi. Hyperoxygenation (to dilate the pulmonary vasculature) or oscillatory
ventilation (to increase the chance of air trapping)
vii. Pulmonary vasodilators and surfactant PRN
f. Special note:
i. Previous treatment included suctioning the mouth and nares upon head
delivery before body delivery
ii. Recent evidence suggests aspiration occurs in utero
iii. Thus, the birth should continue without interruption and the baby
handed to a neonatal team member for evaluation and treatment
16. Perinatal Asphyxia:
a. General term, used to refer to a neonate's inability to successfully transition to
extrauterine life and be breathing well on their own within 1 minute or so of
delivery
i. Perinatal acidosis (deprivation of oxygen during the birth process)
ii. Most common clinical insult in perinatal period
b. Risk factors:
i. Any condition that that reduces O2 delivery to the fetus, including, but
not limited to:
1. Birth trauma
2. Intrauterine asphyxia (cord compression or prolapse, maternal
HTN)
3. Meconium aspiration
4. Sepsis
5. Malformation (congenital anomalies)
6. Hypovolemic shock (from abruption, placenta previa, cord
rupture)
c. Early ID of risk, early recognition of symptoms, early intervention = improved
perinatal outcomes
d. Treatment/Management:
i. 10% require active resuscitation attempts:
1. Dry newborn quickly, place under radiant heater
2. Suction nose/mouth
3. Begin resuscitation procedure
4. Continue compressions until newborn has pulse >100 with good
respiratory effort and pink tongue
ii. After resuscitation:
1. Monitor VS and O2 levels
2. Maintain a neutral thermal environment to prevent hypothermia
3. Check BG levels and observe for signs of hypoglycemia

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e. Complications:
i. Cerebral palsy, mental retardation, speech disorders, hearing and/or
visual impairment, and learning disabilities
17. Nursing Management of Acquired Newborn Conditions:
a. Infants of Diabetic Mothers (IDM)
i. Macrosomia (LGA) – due to maternal hyperglycemia and fetal response of
hyperinsulinemia which leads to somatic growth (pp. 921-22, Table 24.1)
ii. Nursing Concerns:
1. Hypoglycemia
2. Birth Trauma – injury occurring during birth (i.e. shoulder dystocia,
brachial plexus injury, etc.)
3. Respiratory Distress Syndrome (RDS)
4. Polycythemia & hyperbilirubinemia
5. Hypocalcemia (tremors, hypotonia, apnea, high-pitched cry,
seizures)
a. Newborn would be at risk for prolonged delay in
parathyroid hormone production and cardiac dysrhythmias
6. Congenital anomalies
iii. Characteristics of IDM:
1. Distended abdomen
2. Wide shoulders
3. Rosy cheeks
4. Excessive subcutaneous fat on extremities
5. Short neck (really, no neck)
6. Buffalo hump over the nape of the neck
iv. Be alert for signs hypoglycemia (may occur immediately after birth or
within an hour)
1. Listlessness
2. Hypotonia
3. Apathy
4. Poor feeding
5. Apneic episodes with a drop in O2 saturation
6. Cyanosis
7. Temperature instability
8. Pallor
9. Sweating
10. Tremors
11. Irritability
12. Seizures
b. Newborns of Substance-Abusing Mothers:

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i. Clinical Findings:
1. Microcephaly
a. Small head
2. Small eyes
3. Thin upper lip
4. Missing philtrum
5. Narrow forehead
6. Micrognathia
7. Low nasal bridge
8. Delayed motor skills
9. Mental retardation
10. Cardiac defects
11. Poor hand-eye coordination
ii. To diagnose a baby with FAS you need the following
1. At least 3 facial abnormalities
2. Less than 10th percentile for growth
3. CNS abnormality

c. Tobacco

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i. Impaired oxygenation of mother and fetus

ii. Fetal growth retardation/SGA, preterm birth, SIDS, chronic respiratory
illness
d. Marijuana
i. Fetal growth retardation and preterm delivery
ii. Increased risk for SGA
iii. Altered responses to visual stimuli, sleep-pattern abnormalities,
photophobia, lack of motor control, hyperirritability, tremulousness, high-
pitched cry
e. Cocaine
i. CNS stimulant, increases temp/HR/BP
ii. Fetal hypoxia, placental abruption, preterm labor
iii. Signs and Symptoms:
1. Congenital anomalies:
a. GU, cardiac, CNS defects, prune belly syndrome
2. Piercing cry, poor feeding, poor sleep patterns, irritability,
hypersensitivity, smaller head circumference, limb defects, poor
visual and auditory responses, hyperextended positioning,
elevated VS secondary to stimulating effect of the drug
iv. Cocaine exposed infants demonstrate poor coordination of sucking and
swallowing → feeding time can be frustrating for the newborn and
caregiver
f. Opioid Abuse:
i. 2 national trends:
1. Increased prevalence of prescription opioid abuse
2. Increased incidence of neonatal abstinence syndrome (NAS)
a. Read the article in the Lecture 10 Module
b. Incidence has quadrupled in the last decade: 14
cases/1000 births in 2014
i. 20 cases/1000 births in 2019
3. Every 25 minutes an NAS baby is born suffering from opioid
withdrawal
ii. Opioid receptors are concentrated in CNS and GI tract
iii. Signs and symptoms of withdrawal:
1. CNS irritability – may last for 7-8 months
2. Autonomic over-reactivity
3. Gastrointestinal tract dysfunction
18. NAS Assessment:
a. Review maternal history and risky behaviors
b. Obtain urine, blood, meconium toxicology screens
c. Assessment tools
i. Finnegan NAS scoring system:
1. Most commonly used; should be done after feedings when the
infant is awake

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2. The higher the score, the greater the opioid effects

a. Scores greater than or equal to 8 on 3 consecutive
evaluations should have some sort of pharmacological
intervention
ii. WITHDRAWAL Acronym:
1. W – wakefulness (sleep duration less than 3 hours after feeding)
2. I – irritability
3. T – temperature variation, tachycardia, tremors
4. H – hyperactivity, high-pitched persistent cry, hyperreflexia,
hypertonus
5. D – diarrhea, diaphoresis, disorganized suck
6. R – respiratory distress, rub marks, rhinorrhea
7. A – apneic attacks, autonomic dysfunction
8. W – weight loss or failure to gain weight
9. A – alkalosis (respiratory)
10. L – lacrimation
d. Signs and Symptoms of withdrawal (Box 24.4, p. 933 – article p. 7):
i. Disturbances in the:
1. Central Nervous System
a. High-pitched cry
b. Hyperactive reflexes
c. Restlessness
d. Seizures
e. Disturbed sleep patterns
f. Hypertonic muscle tone
g. Constant movement
2. Metabolic, vasomotor, and respiratory systems
a. Fever
b. Frequent yawning
c. Mottling of the skin
d. Sweating
e. Frequent sneezing
f. Nasal flaring
g. Tachypnea (> 60 breaths per minute)
h. Apnea
3. Gastrointestinal system
a. Poor feeding
b. Frantic sucking or rooting
c. Loose or watery stools
d. Regurgitation or projectile vomiting
19. NAS Nursing Management:
a. Promote comfort
i. Low stimulation, low lighting
ii. Swaddle, pacifier, calm approach

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b. Meet nutritional needs

i. Frequent small feedings
ii. Benefits of breastfeeding for the baby are good, even with Mom in
treatment
iii. Strict I&O, daily weight
c. Prevent skin breakdown, weight loss, dehydration
d. Administer meds based on NAS scores (>8)
i. Opioid (morphine, buprenorphine or methadone)
ii. 50-80% of infants get pharmacological management
iii. Phenobarbital to control breakthrough symptoms
e. Promote parent-newborn interactions, educate & refer
20. NAS - Long-term Outcomes for Babies:
a. Poor cognitive, perceptual and memory skills
b. Hyperactivity and impulsivity
c. Short attention span
d. Poor verbal and performance skills
e. Vision and hearing problems
f. At higher risk for child abuse and neglect
g. Risk for future substance abuse
h. Sleep disturbances

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Pediatric Respiratory Disorders #1

1. A&P Considerations:
a. Infants are obligate nose breathers
i. Don’t breathe through their mouth
b. Large tongues and tonsils
i. In relation to their oropharynx which can cause an obstruction
c. Small trachea
d. Underdeveloped larynx
i. Increased risk for aspiration
e. Lower respiratory structures
i. Bifurcation of the trachea (right or left to go into the lungs)
ii. Must know where the bifurcation is so as not to cause issues when
suctioning
f. Lower airways
i. Narrower bronchi and bronchioles
ii. Fewer alveoli
1. Increased risk for hypoxia and CO2 retention
g. Chest wall
i. Movement dependent on the diaphragm
2. Respiratory Assessment:
a. Rate, Rhythm, Ease of Breathing
i. Slow or irregular respiratory rate in an acutely ill infant or child is an
ominous sign
b. Infection Assessment:
i. Symptoms
1. Tachypnea
a. Possible causes besides infection – heart or lung disease,
anemia (result of trying to get oxygen into the blood and
carry it where it needs to go)
2. Bradypnea
a. Possible causes besides infection – respiratory and/or liver
failure
3. Cough:
a. Need to know the following info:
i. Timing of it
1. This is important for children with
undiagnosed asthma (nocturnal coughing is
an early sign of asthma)
ii. What it sounds like
iii. How often it’s happening
iv. Characteristics of it (barky, wheezy, stridorous)

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ii. Chest pain?

iii. Cyanosis?
iv. Signs and symptoms of a respiratory infection (nose to the lungs)?
v. Red throat?
vi. Age
1. Maternal antibody protection until approx. 3 months
2. 3-6 months child is developing their own antibodies
a. Still at risk for getting sick (pertussis specifically)
vii. Size (of the airways)
1. Edema + secretions = problems
viii. Seasons
ix. Decreased resistance
1. Immune deficiencies
2. Asthma or cystic fibrosis
3. Common Pediatric Respiratory Testing (same as the adults):
a. Pulmonary function tests (PFTs)
i. Cystic fibrosis and asthma
ii. Most accurate in children over 5 years of age
b. Bronchoscopy
c. Nasopharyngeal wash
i. Done for children suspected of having influenza, pertussis, COVID
ii. Only done once, all items mentioned are tested for
d. Apnea-bradycardia monitors
e. Pulse oximetry
i. Results can be impacted by ambient light (fluorescent specifically)
ii. Keep a sock on the pt. to minimize light exposure
1. Added benefit – helps the child keep the pulse oximeter on their
foot
4. Acute Upper Respiratory Tract Infections:
a. Nasopharyngitis:
i. Signs and Symptoms:
1. 7-10 days in duration, clear to yellow thin nasal secretions
2. Hoarseness with sore throat
3. Dry cough
4. Fatigue
5. Decreased appetite
6. +/- fever (comes and goes)
ii. Can be complicated by a secondary bacterial infection
iii. Management:
1. Directed toward symptom relief
2. Inspect for edema and vasodilation of the mucosa
3. Nasal washes with saline drops
4. Bulb suctioning
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a. Especially prior to feeding for very young children

5. Humidified air
6. Shower steam
7. Hydration
8. Cool mist vaporizers to loosen secretions
iv. Treatment:
1. Care with combo cold remedies (typically OTC)
a. Side effects:
i. Hypertension
ii. Tachycardia
iii. Sleeplessness
b. Take Note:
i. Products containing acetaminophen may mask a
fever in a child who is developing a secondary
bacterial infection
ii. 2007 – OTC cold meds containing decongestants
intended for use in infants and toddlers were
removed from the market (not effective, known to
have potentially serious side effects)
iii. Safety of these products for children 2-11 years of
age is still under review by the FDA
v. Family Teaching:
1. Recognize worsening symptoms
2. Prolonged (greater than 10 days) or new fever
3. Increased throat pain or lymphadenitis (indicative more of a
bacterial throat infection)
4. Worsening cough or lasting > 10 days, chest pain, dyspnea
5. Earache, headache, sinus pain
6. Irritability
b. Sinusitis:
i. When is it sinusitis instead of a cold?
1. Cold symptoms not improving after 7-10 days
2. New onset fever and/or cough
3. Halitosis (bad breath)
4. Eyelid edema
5. Facial pain may be present but is a poor indicator in children
ii. Bacterial infection of the paranasal sinuses
iii. Treatment:
1. Antibiotics
2. NS nose drops or spray
3. Cool mist humidifiers
4. Adequate oral fluid intake
c. Pharyngitis (back of the throat):

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i. Viral (80% of the time it is viral)

1. Occurs with cold symptoms
2. Self-limited
3. Only symptomatic care is needed
ii. Bacterial
1. Occurs without cold symptoms
2. Onset is abrupt
3. Group A Streptococcus
4. Treated with penicillin for 10 days
5. Diagnosis:
a. Only by throat culture, not inspection
b. Swab them twice (once for in office eval, send the other to
the lab – reducing possibility of a false negative or positive)
c. Child does not need to be on abx while waiting for results
i. Evidence shows that if the child holds off abx
treatment for a couple of days, that resistance to
the bacteria increases
iii. Signs and Symptoms:

iv. Complications of Group A Streptococcus Pharyngitis (strep throat):

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d. Peritonsillar Abscess:
i. Signs and Symptoms:
1. “Hot potato voice”
2. Fever
3. Sore throat
4. Deviation of the ulna away from the involved side
5. Swollen and inflamed tonsils
ii. Treatment:
1. Viral infections require only symptomatic treatment
a. Rest, warm fluids, salt-water gargles
2. Bacterial treatment is the same for bacterial pharyngitis
a. Antibiotic therapy
3. Aspiration or incision and drainage
4. Antipyretic and analgesics
5. Tonsillectomy (10% of cases)
a. Tonsillectomy (postop care & going home)

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e. Laryngotracheobronchitis (“Spasmodic Croup”):

i. Viral infection
ii. Most frequently affected are children between 3 months and 3 years
iii. Signs and Symptoms:
1. Low-grade fever
2. Restlessness
3. Inflammation of the larynx, trachea, and bronchus
4. Edema and mucus that obstruct the airway
5. Hoarseness
6. Presents with inspiratory stridor
a. Pertussis is more of a wheezing sound
7. “Barky cough”
a. Occurs suddenly, and tends to be worse at night
8. Retractions
iv. Treatment:
1. Cold air
2. Keep the child quiet
3. Discourage crying
4. Allow the child to sit up (in your arms)
5. Encourage rest
6. Fluid intake
7. If stridor occurs, take the child into a steamy bathroom
8. Corticosteroid medications may be prescribed
v. When to call your provider:
1. Child breathes faster
2. Retractions
3. Labored breathing
4. Nostril flaring
5. Cyanosis of the lips or nails
6. Cough or stridor does not improve with exposure to moist air

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7. Restlessness or the child becomes confused

8. Drooling
9. Child cannot swallow
f. Epiglottitis:
i. Thin flap of cartilage that covers the top of larynx during swallowing
1. Protects the trachea from having food go down it
ii. Very rare, medical emergency
iii. Child will look VERY sick
iv. Sudden onset
1. Usually caused by HiB
v. Signs and Symptoms:
1. Drool
2. Agitated
3. No cough
4. Restless
5. Irritable
6. Sit hunched over (tripod position)
7. Froggy, muffled voice (dysphonia)
8. Substernal retractions
9. Sore throat
10. High fever
vi. If child is suspected of having this, do NOT do an oral exam to look at the
throat (child could develop distress and an occluded airway)
1. No cultures done by the nurse
vii. Have trach equipment at bedside in case of full occlusion
viii. Administer abx therapy starting with an IV, then transition to oral to
complete a 10-day course

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5. Ear Infections:
a. 3 types:
i. Acute Otitis Media (AOM)
ii. Otitis Media Effusion (OME)
iii. Otitis Externa (OE)
b. Ear infections are inflammation and infection of the middle ear
c. Secretions keep fluid from draining out of the middle ear
d. Bacteria from the back of the throat goes up the eustachian tube and grows in
the fluid that’s trapped in there
e. As face elongates (grows), eustachian tubes develop the slant which helps
prevent ear infections
f. Lower incidence of otitis media in infants who are breastfed
i. Possibly due to presence of IgA in breastmilk and semi-vertical feeding
position
6. Acute Otitis Media (AOM):
a. Signs and Symptoms:
i. Fever
ii. Otalgia-PAIN
iii. Fussiness
iv. Poor feeding

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v. Night awakening
vi. Bulging yellow or red tympanic membrane
vii. Crying
viii. Lethargy
ix. Purulent material in the middle ear
x. Decreased or no tympanic movement with pneumatic otoscopy
xi. Tugging at ears
1. This is pretty unusual after age 6
xii. Fluid draining from ear
1. Fluid could be coming from more than one area
b. Risk Factors:
i. Young age
1. 1st episode of AOM before the age of 3 months
a. More than likely, this child will have repeated infections
ii. Recent URIs
iii. Possibly allergies
iv. Craniofacial anomalies
v. Crowded living environment
vi. Exposure to passive smoking
vii. Day care attendance
viii. Previous AOM or OME
ix. Bottle fed (formula only, never having had breast milk)
c. Management:
i. When feeding, children should not be laid flat but kept at a 45-degree
angle or so
1. Baby laying on flat and drinking from a bottle, the milk (formula or
breast milk) can make its way into the eustachian tube
a. Since it’s sweet, that provides food for the bacteria
d. To Treat or Not to Treat?
i. AAP recommends “watchful waiting” for some
1. Child 6 months to 2 years:
a. Unilateral, symptoms are not severe, no ear drainage
(don’t treat)
2. Child older than 2:
a. Unilateral or bilateral, symptoms are not severe, no ear
drainage (don’t treat)
ii. Severe symptoms as defined by the AAP:
1. Temperature of 102.2 or higher
2. Moderate to severe pain for 48 hours or more
e. Treatment:
i. Abx’s for children over 6 months who have severe manifestations for
more than 2 days
ii. If symptoms are not severe, abx therapy may be withheld for 48-72 hours

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1. If the child worsens or does not improve, abx therapy will begin
7. Otitis Media Effusion (OME):
a. Fluid produced during ear infection does not go away
b. No fever, no pain
c. Signs and Symptoms:
i. May have a feeling of fullness in their ear
ii. Sound may be muffled
iii. Balance disturbances
iv. Orange discoloration of the tympanic membrane with decreased
movement
v. Vague findings including rhinitis, cough, and diarrhea
d. If fluid remains for more than 3 months, or they fail a hearing test:
i. May need tubes put in to have the effusion drained
ii. Does not prevent ear infections, but allows the fluid out so the child can
hear

8. Complications of Ear Infections:

9. Pressure Equalizing Tube:

a. Surgery is called a myringotomy

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b. Tubes allow air to get in (makes it more difficult to produce the fluid) and allows
for drainage of any fluid in the space
c. Postop:
i. Can not get fluid in the ear!
1. Wear ear plugs or Vaseline impregnated cotton
ii. Ear should not be cleaned if it’s draining a lot (go to the doctor)
d. Tubes typically fall out on their own
10. Otitis Externa (OE):
a. Infection of the external ear canal
b. Bacterial growth from moisture
c. Signs and Symptoms:
i. Itching of canal
ii. Drainage
iii. Pain (to the point of possibly needing narcotics)
d. Treatment:
i. Antibiotic (or antifungal) ear drops
ii. Drying canal well to decrease reoccurrence
iii. If canal is so swollen drops can’t get in, a wick (like on a candle) has to be
put in so the fluid can carry down it
iv. Warm compresses can sometimes help
11. Nursing Care AOM & OE:
a. Education:
i. Feeding upright (hold them, don’t prop them)
ii. Breastfeeding until at least 6 months
iii. Immunizations up to date
iv. Stay away from smokers
v. Keep child away from people who are sick
vi. Wear ear plugs if they have PE tubes
b. OE Prevention:
i. Do not wear ear buds
ii. Do not use cotton swabs
iii. Ear plugs when swimming (especially in lake water)
iv. Acetic acid drops to change the pH
v. Drying the ear with a hairdryer on a low setting

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Pediatric Respiratory Disorders #2

1. Acute Lower Respiratory Tract Infections:
a. Bronchiolitis:
i. Inflammation and infection of the bronchioles (sound is “wheezing”)
b. Pneumonia:
i. Has a crackling sound on auscultation
c. Note: if a child coughs and the secretions are clear, that means the infection is
higher up in the lungs, which is less concerning
d. Note: in a tachypneic infant, slowing of the respiratory rate does not necessarily
indicate improvement
i. Could be a sign of tiring, CO2 retention, may soon be followed by apnea
2. Bronchiolitis:
a. Don’t appear too sick in the early days, until they get the wheezing
b. Hypoxia is common
c. Breastfeeding is helpful (maternal antibodies)
d. Diagnosis: np wash & x-ray
e. Season = fall and winter
f. Signs & Symptoms:
i. Initially:
1. Rhinorrhea
2. Intermittent fever
3. Pharyngitis
4. Coughing
5. Sneezing
6. Wheezing
7. Possible ear or eye infection
ii. Illness progression:
1. Fever
2. Tachypnea
3. Retractions
4. Refusal to nurse or bottle feed
5. Copious secretions
iii. Severe illness:
1. Tachypnea > 70/min
2. Listlessness
3. Apneic spells
4. Poor air exchange
5. Poor breath sounds
6. cyanosis
g. Treatment:

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i. Hydration initially (oral or IV)

ii. NP suctioning
iii. O2 to maintain oxygen levels ≥ 90%
iv. Bronchodilator treatment
v. May end up in the ICU on mechanical ventilation
3. Bronchiolitis caused by respiratory syncytial virus (RSV):
a. Preventive measures:
i. Strict hand washing in day care centers and at home
ii. Droplet precautions for hospitalized pt.’s
b. Prevention for certain populations:
i. palivizumab (Synagis) injection
4. Apnea:
a. Absence of breathing for > 20 seconds in neonates and children
b. May be central (unrelated to any other cause) or may occur with other illnesses
i. Examples: sepsis, respiratory infection, cardiac or neurologic
disturbances, child abuse, or poisoning
c. ALTE (acute life-threatening event):
i. Some combination of apnea, color changes, muscle tone changes,
coughing or gagging
d. Treatment:
i. If its a result of another disorder, treatment is directed at that disorder
ii. Caffeine or theophylline is sometimes administered (primarily in
premature infants)
5. Pneumonia:
a. 2 types:
i. Viral
1. Most often in young children, its viral
2. Treatment is supportive care
a. Administer oxygen with cool mist
b. Monitor pulse ox
c. Antipyretics for fever
d. Monitor I&O
e. CPT and postural drainage
ii. Bacterial
1. Abrupt onset after an URI
2. Pt. will appear sick
3. Signs and symptoms:
a. Fever
b. Tachypnea
c. Cough
d. Chest pain
e. Retractions
f. Nasal flaring

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g. Adventitious breath sounds (rhonchi, fine crackles)

h. Pallor progressing to cyanosis
i. Irritability, restless, lethargy
j. Malaise
k. Abdominal pain
i. This may not be GI pain, but referred pain from the
lower lungs since they “touch” each other
4. Treatment:
a. Encourage rest
b. IV antibiotics
c. Monitor I&O
d. Antipyretics for fever
e. CPT and postural drainage may be helpful
f. IV fluids
g. Administer oxygen
h. Monitor pulse ox
iii. Complications (both types):
1. Pneumothorax
2. Pleural effusion
6. Acute Noninfectious Disorder:
a. Foreign Body Aspiration:
i. Solid or liquid aspirated into the respiratory tract
ii. 6 months to about 4 years tend to be at risk
1. Main group is toddlers (and those developmentally challenged)
iii. Symptoms: sudden onset of coughing or wheezing, difficulty breathing, or
someone witnessed it
iv. Stridor – obstruction is in the upper respiratory tract (child may be able to
cough It out)
v. Wheezing and decreased air movement if the object is in the bronchus
(lower respiratory tract)
vi. Complications:
1. Need for a bronchoscopy (going to get it)
2. Pneumonia (especially from a liquid)
3. Respiratory distress/failure
4. Death
vii. Nursing management:
1. Education is the most important thing
viii. Most common aspirated items: food (peanuts, non cut-up grapes, seeds)
in younger children, pins and fingernails for older children
ix. May not be noticed for a few days until onset of symptoms
7. Chronic Respiratory Disorders:
a. Allergic Rhinitis (allergic nose):

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i. Intermittent inflammatory state caused by IgE

1. IgE binds to cells in the nose → immune response → histamine
release → swelling and mucus production

b. Risk Factors:
i. Atopic diseases of childhood:
1. Asthma
2. Allergic rhinitis
3. Atopic dermatitis (aka, eczema)
ii. Tobacco smoke
iii. Pollution
iv. Recurrent viral infections
v. Early introduction of certain foods????
c. Teaching Guidelines 40.4:
i. Tobacco – avoid all exposure
ii. Dust mites – use pillow and mattress covers, wash linens q weekly in hot
water, blinds rather than curtains, remove stuffed animals or minimize
their number (wash them weekly), reduce indoor humidity to <50%,
remove carpets, clean solid-surface floors with wet mop weekly
iii. Pet dander – remove them from the home (this is what the book says),
keep them off of carpets and upholstered furniture
iv. Cockroaches – keep kitchen very clean, avoid leaving food or drinks out,
use pesticides
v. Indoor molds – repair water leaks, use dehumidifier (especially in the
basement), reduce indoor humidity to <50%
vi. Outdoor molds, pollen, and air pollution – avoid going out when mold
and pollen counts are high
8. Asthma:

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a. Leading cause of illness in children

b. Lung damage may be apparent by the age of 6
i. If the child wheezes a lot, get them seen!
c. Reversible with medication
i. Treatment is a step wise approach (least amount of medication
necessary)
9. Asthma-Severity:
a. Mild intermittent:
i. Doesn’t happen very often
ii. Symptoms < 2x’s per week
iii. Nocturnal issues < 2x’s per month
iv. Pulmonary function > 80% to normal
b. Mild persistent:
i. Symptoms > 2x’s per week, but not daily
ii. Nocturnal issues > 2x’s per month
iii. Pulmonary function > 80% to normal
c. Moderate persistent:
i. Symptoms daily
ii. Nocturnal issues > 1 per week
iii. Pulmonary function 60-80% of normal
d. Severe persistent:
i. Symptoms are continuous throughout the day
ii. Frequent nocturnal issues
iii. Activity limitations
iv. Pulmonary function < 60% of normal
10. What Does the Peak Flow Reading Mean?
a. Objective measurement of lung function
b. Child can learn to perform the test to help determine status of their asthma
c. Can provide early identification of subtle symptoms
d. Early treatment can help decrease the risk of permanent lung changes
i. Lung remodeling – tissue changes how it looks and functions
e. Family instructions to use the peak flow meter:
i. Test should be done when the child is feeling well, not sick
1. Set the arrow on the meter to zero
2. Stand or sit upright

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3. Deep breath with lips tightly around the meter

4. Blow out hard and fast
5. Repeat 3x’s and record the highest “score”
f. Peak flow readings are done twice a day:
i. Green: >80% of expected peak flow
ii. Yellow: 50-80% of expected peak flow
iii. Red: < 50% of expected peak flow
g. A patient will have a “personal best” that is his/her expected peak flow when
well
i. This helps to determine severity of their illness when ill
11. Medications:

12. Short acting ß2-Agonists for “Rescue” in Acute Exacerbations:

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13. Corticosteroids in Acute Exacerbations:

a. 2 types:
i. Prednisolone – given orally (1-2 mg/kg/day; max per day is 60mg)
ii. Methylprednisolone sodium – given IV for hospitalized pt.’s
b. Decrease inflammation to treat airflow obstruction
c. Give the lowest dose possible to avoid side effects
14. Anti-inflammatory Agents for Control & Prevention:
a. Corticosteroids
i. To control symptoms and reduce bronchial hyperresponsiveness
ii. Decreases inflammation, which decreases airflow obstruction
iii. Inhaled
iv. This is the med that is most often forgotten about by parents (since it’s
supposed to be every day, and their child may not be exhibiting
symptoms)
1. fluticasone proprionate
2. budesonide
v. Side effects:
1. Oral thrush (rinse mouth after dose)
2. Slight problem with growth and decreased bone density (with
high dose treatments)
15. Cystic Fibrosis:

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16. Prenatal or Natal Carrier Screening for Cystic Fibrosis:

a. Patient tests negative, no need to test partner
b. Patient tests positive, test the partner
c. Patient and partner both test positive
i. If pregnant, can do chorionic villus sampling or an amniocentesis to see if
the fetus has cystic fibrosis
ii. If not pregnant but trying to be, discuss options with the obstetrician
1. Fertility treatment to avoid the CF gene
2. Adoption
17. Cystic Fibrosis – What is it?

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18. Sweat Chloride Testing:

a. Done on newborns who show positive on their newborn screening
i. Newborn screening could give a false positive (child is a carrier, but does
not have the condition)
b. All positive tests should be repeated at a different time and/or diagnosis
confirmed by genetic testing
19. Who do we Suspect has Cystic Fibrosis?
a. Health History:
i. Meconium ileus (one of the 1st signs)
1. Newborn doesn’t stool within 24 hours of birth
ii. Steatorrhea (fat in the stool)
iii. Chronic cough
iv. Activity intolerance
v. Significant constipation
vi. Poor weight gain despite eating well
20. Cystic Fibrosis: Effects on the Body:
a. Gastrointestinal:
i. Malabsorption due to pancreatic insufficiency
ii. Fatty stools
iii. Poor growth
b. Pulmonary:
i. Clogged airways:
1. Leads to obstruction → inflammation → chronic infections, tissue
damage, respiratory failure

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ii. Wheezing
iii. Secondary bacterial infections
1. S. Aureus, pseudomonas aeruginosa are possible, even though
they are not common in the lungs
21. Gastrointestinal Management:

22. Pulmonary Management Goals:

a. Maximize Lung Function
b. Minimize Pulmonary Complications
c. How do we do these 2 things?
i. CPT 2-4 times/day when well; more when sick
1. CPT (chest physiotherapy) helps to get secretions out of the lungs
ii. Medications:
1. Bronchodilators
2. Inhaled corticosteroids
3. Inhaled antibiotics (more efficient)
4. Inhaled mucolytics
a. dornase alpha
iii. Postural Drainage:
1. Technique for infants and young children for loosening mucus in
the airway so that it may be coughed out
2. Tapping is performed in certain areas with the pt. in different
positions
23. Cystic Fibrosis Management:
a. Multidisciplinary approach
i. CF clinic every 2-3 months

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1. Monitoring of growth and development

2. Assessment of lung function with PFTs
3. Assessment of GI tract for malabsorption symptoms:
a. Pancreatic enzyme administration
4. Monitoring for complications of treatment
5. Assessment of psychosocial issues
24. Cystic Fibrosis Education for Parents and Patients:
a. Chest physiotherapy and postural drainage techniques and timing
b. Proper caloric intake and diet (will need to be increased)
c. Correct use and cleaning of equipment
d. Learn how to recognize early signs of infection and complications
e. Know when to seek medical care

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The Child with a Gastrointestinal Disorder

1. Variations in Pediatric A&P:
a. Everything is smaller and still growing
b. GI tract is immature until approx. 2 years of age
c. Mouth is common portal of entry for infection because of children’s behavior
d. Increased incidence of reflux (lower esophageal sphincter is underdeveloped)
i. Examples) spitting up, “wet burps”
e. Hydrochloric acid levels do not mature until 6 months of age
f. Intestinal length is half of what it would be in an adult
g. Liver and pancreas are also assessed when dealing with the GI tract
i. Both organs are immature for quite some time
2. Nursing Assessment:
a. Health history:
i. Growth patterns
ii. Dietary concerns
iii. Toilet training and bowel patterns
1. Constipation is a “normal” thing in kids
2. How often do they go?
3. Consistency of stool?
iv. Patient history
v. Family history
b. Diagnostic testing:
i. Esophageal pH probe
1. Used to determine GERD
2. Probe thru the nose to just above the stomach (checking the
esophageal sphincter); left in for 24 hours
ii. Ultrasound (abdominal)
iii. KUB (x-ray of the abdomen)
iv. Barium studies
1. Don’t forget to encourage lots of water post-procedure
v. Stool studies
c. Physical Exam (remember to listen before percussing/palpating):
i. Inspection & Observation
1. Abdominal size and shape
ii. Auscultation
1. All 4 quadrants (hypo, hyper, or absent)
iii. Percussion
1. Tympanic over most areas, dull over organs
iv. Palpation
1. Should feel soft
3. Structural Anomalies of the GI Tract:
a. Cleft Lip and Palate:

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i. One of the most common congenital anomalies

ii. Pathophysiology:
1. Develops early on in gestation (i.e. 5-9 weeks of life)
2. Can also be associated with other genetic issues
3. 50% of kids have both (lip and palate)
4. Can be either unilateral cleft (more common) or bilateral
iii. Complications:
1. Increased risk for aspiration
2. Feeding difficulties
3. Dentation issues
4. Increased risk for ear infections
5. Speech and language difficulties
iv. Medical Management:
1. Team approach (oral surgeons, nurses, ENT specialists,
orthodontists, social workers, speech/language therapists)
2. Cleft lip repaired first and earlier (3-6 months of age)
3. Cleft palate done later, and after lip (if they have both conditions)
a. 6-12 months of age
b. Goal is to treat before child learns to speak
4. Advise parents that “revisions” (additional surgeries and
therapies) may be needed as the child grows
v. Risk factors:
1. Tends to happen more in males
2. Possible hereditary
vi. Physical exam:
1. Can palpate the cleft
2. If it’s not felt, during first feeding there may be choking or gagging
by the baby
vii. Family education:
1. Parents must know CPR due to ↑ r/f aspiration and choking
2. Bottle feeding recommended
3. Breast feeding contraindicated, but the mother should pump and
feed the baby breastmilk via bottle
viii. Post-Op Nursing Care (Cleft Lip):
1. Arm restraints are kept on all the time for the 1st 10 days
a. Used bilaterally
b. Take them off 1 at a time every few hours (maybe during
feeding)
c. Keeps the baby from grabbing at the sutures (Logan Bow)
2. C – Calming techniques
a. Prevent vigorous and sustained crying (can pull on the
sutures)
3. L – Lie on back
4. E – Evaluate airway

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5. F – Feeding
6. T – Teaching
7. L – Lip protection (Logan bow)
8. I – Infection
9. P – Parent bonding
a. Parents may not be prepared for the visual “shock” of the
condition
ix. Post-Op Nursing Care (Cleft Palate):
1. More painful procedure
2. Be aware of swelling in the back of the throat
3. 1st 3 weeks, goal is to protect the suture line
a. Takes approx. 3 weeks for sutures to heal
b. Child will be on full liquids for 2-3 weeks (no solids)
c. Avoid straws/sippy cups that have a long reach
d. No pacifiers (do not want a lot of sucking)
e. A little bit of water after they finish feeding
4. Arm restraints may be needed (especially for a thumb sucker)
4. Acute GI Disorders:
a. Hypertrophic Pyloric Stenosis:
i. Pathophysiology:
1. Pylorus becomes hypertrophied
2. Stenosis of the pyloric sphincter
3. Leads to obstruction
ii. Risk Factors:
1. Males are greater risk
2. Family history
iii. Signs and Symptoms:
1. Non-bilious emesis 30-60 minutes after feeding (KEY FINDING)
a. Can be blood tinged
2. Hungry and crying despite having been fed
3. Progressive weight loss
4. Progressive and severe dehydration
a. Sunken eyes
b. No tears when crying
c. Sunken soft spot on the top of the head
d. Less urination
5. “Olive shaped” mass in upper abdomen that is palpable
6. Failure to gain weight
iv. Treatment:
1. Requires surgery to fix it (pyloromyotomy) a month or 2 after birth
v. Management:
1. Fluid and electrolyte management
2. Parental education

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3. Pre & Post-op care

4. Resume feedings (clear liquids at first)
b. Intussusception:
i. Pathophysiology:
1. Telescoping of the bowel into another segment; portion folds in
on itself
2. Tends to happen in children < 2
3. Edema and impaired blood circulation
4. Partial or total bowel obstruction
ii. Signs & Symptoms:
1. Sudden onset intermittent pain
2. Bilious emesis (different than pyloric stenosis)
3. “Currant jelly” stools
4. Lethargy
5. Fever
6. “Sausage”-shaped mass on palpation
7. Tender, distended abdomen
iii. Diagnosis:
1. Ultrasound
iv. Treatment:
1. Barium or air enema
a. If the air enema doesn’t help, then surgery would be
required
c. Appendicitis:
i. Pathophysiology:
1. Obstruction of the appendix
a. Usually due to fecal matter
2. Increased pressure
3. Edema
4. Bacterial overgrowth causing infection
5. Perforation
ii. Signs and Symptoms:
1. Right lower quadrant pain
2. Nausea and vomiting
3. Frequent small soft stools
4. Fever
5. Rigid abdomen
6. Anorexia
7. Tachycardia
8. Diarrhea or constipation
9. Decreased or absent bowel sounds
iii. Assessment:
1. McBurney’s Point (RLQ)
a. Rebound tenderness

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2. Labs (looking for infection and/or bleeding)

3. CT scan or ultrasound
iv. Appendicitis (2 types):
1. Perforated (Complicated)
a. Emergency Appendectomy
i. Drainage and Irrigation of peritoneal cavity
ii. IV antibiotics 7-14 days
b. Antibiotics only
i. Initial antibiotic therapy with interval
appendectomy up to 6 weeks later OR Antibiotic
treatment only
2. Non-Perforated (Uncomplicated)
a. Appendectomy - pre-op antibiotics, fluids and electrolytes,
pain meds and possible post-op antibiotics
b. Antibiotic treatment only may be as effective as surgery
5. Chronic GI Disorders:
a. Gastroesophageal Reflux (GER):
i. Signs and Symptoms:
1. Failure to thrive/ weight loss
2. Respiratory problems
3. Hungry/ irritability
4. “Wet burps” or vomiting after feeds
5. Infant: Pain with feeding
a. Results in infant posturing (arched back; Sandifer
Syndrome)
6. Older child:
a. Dental erosion
b. Heartburn
c. Abdominal pain
d. Difficulty swallowing
e. Chronic cough
f. Noncardiac chest pain
ii. Management:
1. Alter feeding techniques – initial treatment
a. Largest concern is aspiration post-feeding
b. Small, frequent feedings
c. Upright positioning for 30-45 minutes after feeding
d. Thickened formula
2. Medications
a. Histamine 2 blockers (Pepcid, Tagamed)
i. Decrease gastric acidity
b. Proton pump inhibitors
i. Reduces gastric acid production
ii. “-zole” medications

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c. Prokinetics
i. Helps stimulate GI motility so the stomach empties
faster
3. Nissen fundoplication (surgical procedure)
a. Makes it a lot more difficult to regurgitate by wrapping the
upper stomach around the esophagus
b. Hirschsprung Disease:
i. Patho:
1. Lack of ganglionic cells (assist in peristalsis) in the bowel which
cause inadequate motility; diagnosed in 1st 3 years of life; impacts
the intestine
ii. Signs and Symptoms:
1. Newborn:
a. Failure to pass meconium within 24-48 hours after birth
b. Episodes of vomiting bile
c. Refusal to eat
d. Abdominal distention
2. Infant:
a. Failure to thrive
b. Constipation
c. Vomiting
d. Episodes of diarrhea and vomiting
3. Child:
a. Undernourished, anemic appearance
b. Abdominal distention
c. Visible peristalsis
d. Palpable fecal mass
e. Constipation
f. Foul-smelling, ribbonlike stool
iii. Diagnosis:
1. Rectal suction biopsy (will show an absence of ganglionic cells)
iv. Treatment:
1. Surgical resection of the bowel with re-anastomosis; “pull-
through” procedure
a. Temporary colostomy may be required
c. Celiac Disease:
i. Pathophysiology:
1. Auto immune disorder
2. Inability to digest gluten (found in wheat, barley, rye, some oats)
3. Damages villi in small intestine
4. Malabsorption leading to malnutrition
ii. Medical management:
1. Gluten-free diet
iii. Signs & Symptoms:

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1. Anemia
a. Due to iron, folate, and B12 are unable to be absorbed
2. Steatorrhea
3. Poor weight gain
4. Abdominal distention
5. Thin extremities
6. Poor muscle tone
iv. Diagnosed via blood test
1. Definitive test is a small bowel biopsy (shows villi atrophy)
v. Management/Treatment:
1. Dietary alterations:
a. Strict gluten-free diet for life
i. Stay away from breads, cakes cereals, pasta,
alcohol, commercial dairy products
b. Vitamins if malnourished
c. Referral to dietician
d. Teaching Guidelines 42.3, p. 1615
i. Food to Avoid:
1. All wheat products (rye, triticale, barley,
oats, or oat bran)
2. Gluten
3. Graham
4. Spelt or durum flour
5. Bulgur
6. Farina
7. Kamut
8. Malt extract
9. Hydrolyzed vegetable protein
10. Any creamed or breaded vegetables
11. Canned baked beans
12. Some French fries
13. Some commercial fruit pie fillings and dried
fruit
14. Any meats or poultry prepared with wheat,
rye, oats, barley, gluten stabilizers, or fillers
for meats
15. Canned meats
16. Self-basting turkey
17. Some egg substitutes
18. Commercial salad dressings
19. Prepared soups
20. Condiments, sauces, and seasonings made
with avoided products
21. Nondairy cream substitutes

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22. Flavored instant coffee

23. Alcohol distilled from cereals
24. Licorice
2. Close monitoring of growth

Nursing Care of the Child with a Cardiovascular Disorder – Part 1

1. Cardiac Disease in Children:
a. Congenital Heart Disease:
i. Child is born with it
ii. Rate is approximately 1 % of live births 0r 32,000 annually
iii. Nearly half of all cases are diagnosed during 1st week of life
iv. 28 % occur along with a syndrome or chromosomal defect
b. Acquired Heart Disease:
i. Happens after birth
ii. Complication of CHD
2. Fetal Heart Development:
a. Heart begins to develop shortly after conception and is completed by 8 weeks
b. Heartbeat begins at about 2 - 3 weeks gestation*
c. Risk factors for disruption of normal development:
i. Maternal substance abuse
ii. Maternal exposure to viruses (rubella, cytomegalovirus, toxoplasmosis)
iii. Maternal diabetes
iv. Family history of CHD
d. In most instances there is no known cause
3. Variations in Heart Structure and Function:
a. Heart size – size of your fist in adults
i. Children under 7 – heart lies more horizontally; apex is higher and found
at 4th intercostal space
ii. As lungs grow - heart displaced downward
iii. By age 6-10 years - heart 10 times birth size and grows more vertically
(apex at 5th IC space)
iv. Adolescence – the heart grows in size with teen’s rapid growth spurt
b. Compliance – less in infants and young children
i. Compliance (flexibility and stretching capability of the heart to
accommodate stroke volume) is less in infants and children
1. Therefore, HR is higher in infants and children
c. Heart rate: higher in infants (average 120) – teens (average 60’s)
4. Obtaining the Health History of Cardiac Patients:
a. Present illness:

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i. Symptoms: activity intolerance, failure to thrive, tachypnea, color change,

sweating around the head with feeds, delayed growth and development
b. Pregnancy History: maternal infections, medications, illness
c. Family History: CHD in the family (siblings have a 3% recurrence risk), sudden
death at an early age
d. Risk factors: DM, obesity, hyperlipidemia; other associated genetic defects
5. Physical Exam:
a. Inspection: general appearance, color, sweating, dysmorphic features, edema
b. Palpation: quality and amplitude of pulses (upper and lower extremities),
hyperactive precordium/thrill, hepatomegaly; femoral pulse is a critical
assessment in infants
c. Auscultation (normal vs. abnormal):
i. Apical pulse for a full minute
ii. Rate and Rhythm
iii. Murmur (most common finding)
1. Location, quality and intensity
2. Relationship to cardiac cycle
3. Variation with position
d. Arterial Blood Pressure
i. Blood pressure should be obtained in upper and lower extremities
e. >50% of newborns have an innocent systolic murmur - usually normal EKG and
CXR
6. Persistent Fatal Circulation:
a. Think either…
i. Patent ductus arteriosus
ii. Patent foremen ovale
7. Murmurs:
a. Normal
b. VSD (ventricular septal defect)
i. Hole in the heart
8. Lab and Diagnostic Testing:
a. CBC, Blood gas
b. ECG
c. Chest X-Ray
d. Echocardiography
e. Cardiac Catheterization
f. Critical Congenital Heart Disease (CCHD) Screening:
i. Pulse oximetry screening 24-48 hours of age recommended
ii. Decreased morbidity and mortality with implementation
iii. Recommended by CDC and AAP since 2011, required in FL since 2013
9. Cardiac Catheterization:
a. Definitive diagnostic study for children with cardiac disease
i. 3 types of catheterizations can be done:
1. Diagnostic
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2. Interventional (correcting a defect)

3. Electrophysiologic
b. Procedure: catheter inserted into blood vessel (Femoral vein) and threaded into
left or right side of heart; can use arteries, veins, or both to access the heart
i. Sedation in children – lasts 1-3 hours
c. Complications: bleeding, infection, arrhythmia
d. Pre-cath Care:
i. History & Physical Exam
ii. Allergies to shellfish or iodine
iii. Mark pedal pulses (location where you found it)
iv. Education
e. Post-cath care:
i. Monitor for complications
ii. VS & O2 sat, I&O’s
1. VS will initially be q 15 min, then hourly
iii. Assess neurovascular status of affected extremity
1. Checking distal pulses, cap refill, sensation, color, temperature,
etc.
iv. Assess dressing, reinforce PRN
v. Bedrest with extremity extended
vi. Pain management
vii. Education
1. Change pressure dressing the day after procedure
a. Inspect the insertion site for redness, irritation, swelling,
drainage, and bleeding
2. Check skin temperature, color, sensation, and pulses on all
extremities for comparison
3. Resume normal diet after procedure
4. Check child’s temp at least once per day for 3 days (report
elevation of 100.4 or higher)
5. Avoid tub baths for approx. 3 days
6. Discourage strenuous exercise or activity for 3 days
7. Watch for changes in child’s appearance (i.e. pallor or cyanosis)
8. Reports of heart “fluttering” or skipping a beat
9. Fever
10. Difficulty breathing
11. Acetaminophen or ibuprofen for pain
10. Congenital Heart Disease:
a. 4 types:
i. Disorders with increased pulmonary blood flow
ii. Disorders with decreased pulmonary blood flow
iii. Obstructive disorders
iv. Mixed defects

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11. Increased Pulmonary Blood Flow/Acyanotic Heart Disease:

a. 2 types:
i. Ventricular septal defect (VSD)
1. Hole in the ventricle (lower chamber)
ii. Patent ductus arteriosis (PDA)
1. Between aorta and pulmonary artery
b. Heart murmur
c. Symptoms of congestive heart failure
d. Left-to-Right Shunt
i. Pressure is greater on the left side of the heart
e. Signs and symptoms will be the SAME for both conditions
12. Ventricular Septal Defect VSD:
a. Oxygenated blood goes back through the lungs
b. Extra pressure and extra flow through the lungs is not a good thing
c. Will show s/s of CHF early on
d. Signs and Symptoms:
i. Murmur
ii. Tachypnea
iii. Heart failure
iv. Poor growth
v. Respiratory infections due to more fluid in the lungs
vi. Peripheral edema
e. Treatment:
i. Many VSDs close spontaneously early in life
ii. VSD Patch Closure (surgical procedure)
13. Patent Ductus Arteriosus:
a. Signs and Symptoms:
i. Murmur
ii. Respiratory infections
iii. Poor growth
iv. Heart failure
v. Widened pulse pressure
vi. As blood is pumped out of the heart, some of it drains into the lungs
b. Treatment: Coil Embolization of PDA
14. Decreased Pulmonary Blood Flow/Cyanotic Heart Lesions:
a. Fairly common problem
b. 4 associated defects present in this type of defect
c. Primary problem is pulmonary stenosis (stenosis = narrowing)
i. This causes decreased blood flow to the lungs
d. Associated VSD (hole in the heart)
e. Overriding aorta
i. Not the correct placement of the aorta
ii. Sits over the heart wall

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f. Right heart muscle gets thickened

i. Decreases stroke volume
ii. Once the condition is fixed, this should correct itself on its own
g. Tetralogy of Fallot (TOF):
i. Signs and Symptoms:
1. Cyanosis: Desaturated blood enters the peripheral circulation
2. Polycythemia: ↑ in RBCs which results from chronic hypoxia
3. Right-to-left shunt (unoxygenated blood mixes with oxygenated
blood)
a. Unoxygenated blood cannot get into the lungs, it’s pushed
into the left side of the heart and put back into circulation
4. Loud harsh murmur
5. O2 sats can be very low (75-85%) and that may just be their
baseline
a. They can survive and be okay with sats this low until the
problem is fixed
b. Still need to know their individual baseline
h. TOF: Hypercyanotic “TET” Spells:
i. Develop suddenly with agitation → increased cyanosis (very purple
looking), hypoxemia, dyspnea
ii. Only kids in the world that can die from cyring
iii. Nursing Care (stay calm):
1. Place infant or child in knee-chest position (increases systemic
vascular resistance & improves pulmonary blood flow)
2. Provide supplemental O2 (temp fix)
3. Administer morphine sulfate (relaxes pulmonary artery, decreases
resp. demands)
4. Supply IV fluids
5. IV propranolol (Inderal): only in very severe cases
iv. Treatment:
1. Surgical repair (can be done in one surgery)
a. Repair the stenosis in the pulmonary valve in the
pulmonary artery
b. Repair the VSD with a patch
c. Survivor rate is 90%
15. Obstructive Disorders:
a. Involve “stenosis” (narrowing in a vessel)
b. Coarctation of the Aorta:
i. More blood flow to the upper extremities than the lower extremities
ii. Increased blood pressure and bounding pulses in upper extremities
compared to lower extremities
iii. Audible murmur, but there are different degrees (mild to severe)
iv. Must check femoral pulses in infants!

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v. In older children – epistaxis (nosebleeds), headaches, leg pain with

activity
c. Management:
i. Mild instances: cardiac cath and “blow it up” with a balloon (widens the
vessel)
1. Doesn’t last for many years, so it would have to be redone
ii. More severe defect: surgical repair (end-to-end anastomosis)
1. Suture lines are put into the aorta
2. Keep the pt. calm
16. Mixed Defects:
a. Defects in which mixing of blood is essential to the survival of the newborn:
i. Transposition of the great arteries (TGA)
ii. Hypoplastic left heart syndrome (HLHS)
17. Transposition of the Great Vessels:
a. Pulmonary artery and aorta are backwards, so the blood doesn’t mix
b. Diagnosed early
c. Putting O2 on these kids will not increase their sats
d. Signs and Symptoms:
i. Severe cyanosis without murmur
e. Management:
i. Administer Prostin to keep PVA open
1. If this doesn’t work, surgery is needed to do an emergency
catherization
a. Once the child stabilizes, then major surgery is needed to
switch the arteries back to where they need to go
18. Hypoplastic Left Heart Syndrome:
a. Entire left side of the heart is not formed properly
b. Signs and symptoms:
i. Increasing cyanosis
ii. Circulatory collapse
c. Management:
i. Palliative care
ii. Transplant surgery
iii. Reconstruction surgery (minimum of 3 open heart surgeries)

Nursing Care of the Child with a Cardiovascular Disorder – Part 2

1. Heart Failure:
a. Relatively common in infants

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b. Heart failure – the hearts inability to pump adequate blood, oxygen, and
nutrients to the body
i Blood backs up into the lungs and systemic circulation
c. Occurs as early as 1 year of age
d. S/S can be subtle, so always listen to the parents
e. Signs and Symptoms:
i Tachypnea (biggest red flag)
ii Poor feeding (baby is struggling to feed and breath)
1. Increased HR
2. Diaphoresis
iii Cyanosis around mouth and eyes
iv Tachycardia
v Edema especially the around eyes, hands, and feet
vi Poor growth (failure to thrive) due to poor feeding
f. Nursing Management:
i Mostly supportive care
ii Promote oxygenation
iii Support cardiac function
1. Digoxin
2. Furosemide
a. For severe HR, these meds are given IV, and as situation
improves, oral meds can be used
iv Daily weights
v Provide adequate nutrition
1. Increased calories
2. Small frequent feedings
vi Promote rest
2. Interventions for the Child with CHD (Careplan pp. 1568-1571)
a. Increase cardiac output
i Monitor VS
ii Monitor cardiac rhythms
iii Observe for signs of hypoxia (tachypnea, cyanosis, tachycardia,
dizziness, and/or restlessness)
iv O2, if needed
v Place child in knees-to-chest (squatting) position
vi Administer meds, as prescribed
vii Monitor for signs of thrombosis (restlessness, seizure, coma, oliguria,
anuria, edema, hematuria, or paralysis)
viii Cluster care
ix Administer fluids to decrease possibility of thrombosis formation
b. Promote tissue perfusion
i Assess LOC, pulse, BP, peripheral perfusion, and skin color

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ii Administer meds as prescribed

iii Monitor pulse ox and ABGs
iv Supplement O2 as needed
v Monitor H&H
vi Strict I&O’s
vii Elevate HOB
viii Change position q 2-4 hours
ix Assess respiratory status and lung sounds regularly
c. Promote adequate nutrition
i Increased calorie meals
1. Due to higher metabolic rate
2. Child – high protein/calorie diet
3. Infant – high-calorie formula or breast milk fortifier
a. May use 24-30 cal/oz. of oil or carbohydrates to add
calories
4. Cardiac pt.’s need more calories per day
a. “Normal” child: 100 cal/kg/day
b. Cardiac pt.: 120-150 cal/kg/day
ii Small, frequent feedings
1. Want to keep energy expenditure low
2. Limit feedings to 20 minutes q 3 hours
3. Gavage remainder
4. Special nipple
iii Monitor growth
1. Daily weights
2. 1 oz. weight gain/day for infants is what we’re looking for
a. More than that, the concern is fluid overload
d. Preventing infection
i PREVENTION IS KEY
ii Maintain strict hand hygiene
iii Assess VS – temperature
iv Avoid contact with ill persons
v Ensure up-to-date immunization status
vi Administer prophylactic antibiotics prior to dental or minor procedures:
1. Infective Endocarditis - IV antibiotics 4 – 6 weeks
2. Amoxicillin is the most commonly prescribed abx
vii palivizumab (Synagis) injection to help with respiratory issues?
e. Promote family processes
i Provide support for child and family
ii Encourage parents to participate in child’s care
iii Provide anticipatory guidance
iv Encourage parents to hold and touch child
v Encourage play with familiar toys
vi Explain plan of care

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vii Recognize vulnerable child syndrome

f. Promote activity (as tolerated)
g. Promote appropriate development
3. Decreased Cardiac Output:
a. Monitor VS
b. Assess cardiac status
c. Administer medications:
i Digoxin
ii Furosemide
4. Digoxin:
a. Increases contractibility of heart and slows the rate
b. Family Education:
i Give BID at 12-hour intervals, without food or fluids
ii Give parents a syringe to measure meds accurately!!
1. Small therapeutic window, monitor levels
iii Forgotten doses – 4-hour rule:
1. If dose is missed >4 hours or child vomits – wait until next dose
2. Notify MD if 2 missed doses
iv Educate about signs of Digoxin toxicity: Nausea, vomiting, decreased
appetite, bradycardia, drowsiness, lethargy
c. Nursing considerations:
i Monitor electrolytes: hypokalemia increases effect of digoxin
(furosemide is the biggest culprit when it comes to lowering K+ levels)
ii Withhold if HR is <60 in adolescents/older children, < 70 in young
children, < 90 in infants
d. When child first comes to the hospital in HR, sometimes a “digitalizing dose” is
initially done
i This is a larger dose of digoxin to get their levels up high enough rapidly
1. Route: IV (slow)
ii May be done for a couple of days before going to PO options
e. Digoxin toxicity: may cause arrhythmias which may prove to be fatal
5. Acquired Heart Disease:
a. 4 types:
i Acute Rheumatic Fever
ii Hypertension
iii Hyperlipidemia
iv Kawasaki Disease
6. Acute Rheumatic Fever:
a. Stems from group A strep infection (pharyngitis)
b. Impacts the following:
i Heart
ii Joints
iii CNS

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c. Impacts kids 5 to 15 years of age

d. Autoimmune response in some individuals
e. Tends to last 6-12 weeks
i Can reoccur with subsequent infections
f. Diagnosis: based on Jones Criteria: either 2 major or 1 major and 2 minor criteria,
following an acute strep infection
i Major criteria:
1. J – joints (polyarthritis)
2. ♥ - carditis (pancarditis)
3. N – nodules
4. E – erythema marginatum (skin rash)
5. S – Sydenham’s chorea (involuntary, random, or jerky movements
[CNS issue])
ii Minor criteria:
1. Fever, ESR, arthralgia, long PR interval
g. Nursing Management:
i Antibiotic therapy: full 10-day course of penicillin therapy
ii Corticosteroids
iii Bed rest – strict!
iv Pain management
v Cardiac Complications: Aortic stenosis, leaking mitral valve
vi Education to child/family
vii Penicillin is the med of choice (daily oral pill, or monthly IM injection)
h. Treatment could be at least 5 months, or until child is 21
i. If there has been damage to the heart or heart valves (mitral or aortic valves), pt.
will need to be on lifelong penicillin prophylaxis
j. Complications:
i Leaky valves
ii Stenosis of the valves
7. Hypertension:
a. Definition: BP consistently above the 95th percentile for gender, age, and height
b. Screening should begin at 3 years – BP norms are based on gender, age &
height; based on 3 separate readings; taken on all 4 extremities
c. Primary hypertension: associated with BMI and waist circumference
d. Secondary hypertension: frequently related to renal or cardiac disease (this is
what we think about when evaluating a young child)
e. HTN in very young children is unusual (more than likely the cause is a cardiac or
renal issue)
f. Since our book was published, the 2017 American Academy of Pediatrics
guidelines for childhood hypertension have come out:
i Changes: BP > 90th percentile now termed “elevated BP”
ii Simplification of BP cut-points for Stage 1 & 2 hypertension

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iii For children 13 yrs. and greater BP cut-points are the same as for adults:
130/80 – 139/89 for stage 1 140/90 for stage 2
iv If a high result is obtained, multiple measurements over 3 subsequent
visits need to be documented before diagnosing with Hypertension
1. If elevated, repeat in 6 months
v Goal is to reduce BP to < 90th percentile for the patients under 13 and
<130/80 in adolescents 13 yrs. and older
g. Nursing management:
i Monitor BP & symptoms
ii Education to child & family
1. Healthy diet
2. Increase physical activity
3. Weight reduction
4. Antihypertensive medications PRN
5. Keep follow-up appointments
8. Hyperlipidemia:
a. Assessment:
i AAP recommendations: Screening > age 2 years
ii Acceptable level: <170 (total cholesterol); <110 LDL
iii Borderline level: 170-199 (total cholesterol); 100-129 LDL
iv Elevated levels: ≥ 200 (total cholesterol); ≥ 130 LDL
b. Health history:
i Very important in families with a history of high cholesterol or heart
disease, diabetes, HTN, smoking, etc.
c. Plot weight and height
d. Nursing Management:
i > 2 years: a risk assessment screening is done based on family history
ii Guidelines recommend universal screening between 9 – 11 yrs. and
again between 18 – 20 yrs.
e. Education:
i Dietary management (possibly refer to a nutritionist)
ii Learn how to read nutrition labels
iii 60 min/day of exercise
iv Medications PRN (statins safe starting at 8 years of age)
f. Goal:
i 50% reduction in LDL levels
9. Kawasaki Disease:
a. Acute systemic vasculitis occurring mostly in young children
b. Peak age 1-2 years
c. 80% less than 4 years of age
d. Most frequently in males and Asian children
e. Cause remains unknown (Illness not explained by other know disease processes)
f. Diagnosis is determined by clinical symptoms (there is no “one thing” that will
determine this)

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g. Kawasaki Disease Diagnostic Criteria:

i Fever of at least 5 days duration AND…
ii the presence of at least 4 of the following 5 conditions:
1. Bilateral conjunctival injection (red, irritated look; not an actual
infection)
2. Changes of lips/oral mucosa (dry, red fissured lips, strawberry
tongue, or oropharyngeal erythema)
a. Dehydration is common
3. Changes of peripheral extremities (erythema of palms/soles,
edema of hands/feet, with subsequent desquamation [peeling of
skin])
4. Polymorphous rash
5. Cervical lymphadenopathy
iii Lab work (results will be nonspecific):
1. ↑ inflammatory markers (Sed. Rate and CRP)
2. Anemia
3. Thrombocytosis (↑ platelets)
4. Occasionally ↑ WBCs
iv An echo should be done right away to rule out Kawasaki Disease
h. Treatment and Nursing Management:
i Earlier treatment is started, greater the likelihood that complications
will be avoided
ii Medications:
1. Intravenous Immunoglobulin (IVIG)
a. Mainstay of treatment for years
b. Blood product, so give it cautiously and slowly (over 10-12
hours)
c. Better outcomes if Kawasaki is identified and IVIG is
administered within the first week of signs and symptoms
presenting
2. Aspirin: high dose while febrile (80-100 mg/kg/day QID), then
decreased dose (3-5 mg/kg/day)
a. Kawasaki is the exception to the rule when it comes to
giving aspirin to those under 19 years of age
b. Since dosing is initially high, be aware of aspirin toxicity
i. Headaches, confusion, dizziness, ringing in the ears,
GI issues
3. Aspirin and IVIG helps to:
a. Reduce inflammation
b. Reduce incidence of coronary artery aneurisms
c. Promote resolution of pre-existing aneurisms
i. Promote comfort, Acetaminophen, Quiet environment, IV fluids

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j. Consult Infectious Disease Specialist and Cardiologist

k. Assess for signs of HF
l. Education:
i Avoid live vaccines (Measles, varicella) for 11 mo. after high dose IVIG
ii Low dose aspirin continues for 6-8 wks. (teach how to identify s/s of
aspirin toxicity)
iii Regular cardiac F/U: Echo at diagnosis (checking for any aneurisms), 3
wks. and 8 wks. after treatment, then at discretion of cardiologist
m. Complications:
i Coronary artery aneurisms
1. May occur as early as 7-10 days after fever onset
2. Peak prevalence 2-4 weeks after onset
3. Up to 50% have cardiac manifestations:
a. Myocarditis (inflammation of the middle layer of the heart)
b. Pericarditis (swelling and inflammation of the pericardium)
c. Conduction disturbances
d. Mitral/aortic regurgitation
n. “30-30-30” rule:
i 30% of kids that get it, will be identified early, treated early, and will not
develop any cardiac involvement
ii 30% will have some sign of cardiac issue
1. With treatment IVIG and aspirin over 6-8 weeks, aneurisms will
resolve (still requires follow-up to confirm this)
iii 30% delay treatment, are never diagnosed, or are resistant to treatment
1. These kids will have some serious cardiac issues which could
require lifetime treatment

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