Reproduction:
Prematurity Case Study
Kelly Hicks, MSN, RNC-OB
Labor and Delivery
Background
Caroline is a Caucasian, 24-year-old G5P4 at
35 weeks gestation with no prenatal care. She
presented to the emergency department
contracting 1-2 minutes apart, reporting
rupture of membranes 18 hours ago. Upon
examination, she was 8 cm and 90% effaced
with fetal heart tones of 180 bpm. Fifteen
minutes after arrival Baby Benjamin was born
via precipitous vaginal delivery at 1859.
Questions
1. What are the implications of Caroline’s
lack of prenatal care?
2. What risks are involved in a precipitous
delivery?
3. What other risk factors are present?
Initial Newborn Assessment
After delivery, Baby Benjamin was admitted to
the newborn nursery around 1915. His Apgar
scores were 5 at one minute and 7 at five
minutes. At one minute, points were deducted
for color, tone, and reflexes. He weighed 4 lbs
9 oz and was 18 ½ inches long. VS: HR 145,
RR 80, T 97.0 axillary, O2 sat 89%. Blood
glucose 35 mg/dL. Upon assessment, he had
nasal flaring, retractions, grunting, and
crackles in bilateral lung fields.
Questions
4. Based on the assessment data, which of
the findings are abnormal and require
intervention?
5. What interventions should the nurse take
at this time?
Initial Interventions
At 1930 Baby Benjamin was given an ounce of
D5W and blow by O2 at 100%. He was placed
under the radiant warmer. Blood and skin
cultures were sent to the lab. A portable chest
x-ray was performed. At 1945 VS: HR 160, RR
92, T 97.0 axillary. With blow by O2 his O2 sat
was 91%, but dropped to 85-87% when taken
away.
Questions
6. Is Baby Benjamin experiencing transient
tachypnea (TTN) or respiratory distress
syndrome (RDS)? Give data to support why
it is one versus the other.
7. What nursing interventions need to be
done next?
Further Assessment
At 2100, Baby Benjamin has a blood glucose
of 42 mg/dL. VS: HR 155, RR 108, T 96.7
axillary O2 sat 90% with blowby O2. The nasal
flaring and retractions have not yet subsided.
He is left under the radiant warmer and given
oxygen therapy via a hood.
Questions
8. Discuss indicators of the presence of
infection.
9. What put the baby at risk for infection?
10. What frequent assessments should be
made at this point?
Worsening Status
At 2300 Baby Benjamin is pale with circumoral
cyanosis. He is difficult to arouse and
continues to having nasal flaring, retractions,
grunting, and is now “singing”. Orders were
received from the pediatrician to start an IV of
D51/2 NS at 5 mL/hr and Baby Benjamin was
transferred to a neonatal intensive care unit
(NICU) 30 miles away.
Questions
11. Why did Baby Benjamin require transfer to
another hospital?
12. What could be the reason behind Baby
Benjamin’s lethargy?
13. Why was he continuing to show signs of
respiratory distress?
At the NICU
At 0100 Baby Benjamin is in the NICU and has
been placed on a ventilator and phototherapy
for hyperbilirubinemia that caused him to be
jaundice.
Questions
14. Why was Baby Benjamin placed on a
ventilator?
15. What caused Baby Benjamin to become
jaundice?
16. What nursing interventions should be done
in regards to phototherapy?
17. Develop a clinical care model for this baby
including psychosocial needs of the family.
Questions with Answers
1. What are the implications of Caroline’s
lack of prenatal care?
Lack of prenatal care can be a result of
substance abuse in the mother that she
does not want revealed. The dates could
be off and the baby might be younger than
35 weeks. There may be congenital
anomalies or issues present that can
affect the baby’s transition. Unknown
maternal blood type, rubella, hepatitis B
HIV and GBS status. Unknown STD status.
Questions with Answers
2.
What risks are involved in a precipitous
delivery?
Baby is at risk for bruising, trauma, palsies,
and hyperbilirubinemia. Mom is at risk for
vaginal tears and PP hemorrhage.
3.
What other risk factors are present?
ROM for 18 hours-risk for infection, neonatal
withdrawal if substance abuse was present.
Preterm delivery, unknown GBS status. Fetal
tachycardia noted prior to delivery.
Questions with Answers
4.
Based on the assessment data, which of the
findings are abnormal and require intervention?
RR too high, T too low, blood glucose too low,
O2 sat too low. Nasal flaring, retractions,
grunting, and crackles in bilateral lung fields all
abnormal.
5.
What interventions should the nurse take at this
time?
Baby needs to be placed in radiant warmer.
Blow by O2 administered. Glucose water given.
Blood sugar rechecked after feeding. Notify MD to
receive orders for chest x-ray.
Questions with Answers
6.
Is Baby Benjamin experiencing transient
tachypnea (TTN) or respiratory distress
syndrome (RDS)? Give data to support why it is
one versus the other.
TTN includes respiratory symptoms with no
cause. Respiratory distress syndrome
occurs in premature babies with a
deficiency in surfactant. Baby Benjamin is
premature and a chest x-ray was performed to
determine the reason behind the respiratory
issues.
Questions with Answers
7.
What nursing interventions need to be done
next?
Recheck baby’s blood glucose. Keep
baby under warmer, checking
temperature every 15 mins. Frequent
vital sign assessment and continue to
administer blow by O2.
Questions with Answers
8.
Discuss indicators of the presence of infection.
Inability to keep temperature and blood
glucose up even with intervention. FHR
tachycardia prior to delivery.
9.
What put the baby at risk for infection?
Prolonged ROM, prematurity, unknown
GBS status.
10. What frequent assessments should be made
at this point?
VS, O2 sats, blood glucose, respiratory
assessment.
Questions with Answers
11. Why did Baby Benjamin require transfer to
another hospital?
The hospital may not be equipped to care for
such a sick, premature baby. It may not be a
level IV and Baby Benjamin may require a
ventilator to assist with the respiratory
symptoms.
12. What could be the reason behind Baby
Benjamin’s lethargy?
Continued low blood glucose, possible
pathologic jaundice since maternal blood type
and Rh factor is unknown. Infection could
spread and become sepsis.
Questions with Answers
13. Why was he continuing to show signs of
respiratory distress?
The baby is premature so the lungs may
not be mature and there may be a
deficiency in surfactant. Infection can be
a cause of some of the distress as well.
Questions with Answers
14. Why was Baby Benjamin placed on a ventilator?
Lack of surfactant results in an inability to
breathe on his own. The ventilator assists
Baby Benjamin in breathing with less
difficulty and without expending so much of his
energy just to breathe.
15. What caused Baby Benjamin to become jaundice?
Pathologic jaundice may be the case if
there is a ABO/Rh incompatibility. The
precipitous delivery can also cause trauma that
will contribute to hyperbilirubinemia.
Questions with Answers
16. What nursing interventions should be done in
regards to phototherapy?
Initial VS with axillary temperature. VS at least
every 4 hours, temperatures at least every 2
hours if not under warmer as well. Eyes and
genitals only covered. Repositioning every 2
hours. Only serum bilirubin checks after
initiation of phototherapy with blood draws with
phototherapy lights off. Monitor I&Os, daily
weights.
Questions
17. Develop a clinical care model for this baby
including psychosocial needs of the family.
Nursing Diagnoses that can be included:
Ineffective Breathing Pattern
Impaired Gas Exchange
Ineffective Thermoregulation
Altered Nutrition: Less than Body Requirements
Ineffective Family Coping: Compromised
Altered Parenting
References
Gregory, D. (2006). Instructor’s manual to
accompany clinical decision making
case studies in maternity and women’s
health. Clifton Park, NY: Thomson
Delmar Learning.
Ladewig, P., London, M. & Davidson, M.
(2010). Contemporary MaternalNewborn Nursing Care. (7th ed.) New
York: Pearson.