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QuestionAnswered step-by-step*/ @font-face {font-family:”Cambria Math”; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-pitch:variable; mso-font-signature:-536858881 -1073711013 9 0 511 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:””; margin:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:”Times New Roman”,serif; mso-fareast-font-family:”Times New Roman”;} p.MsoFooter, li.MsoFooter, div.MsoFooter {mso-style-unhide:no; mso-style-link:”Footer Char”; margin:0in; mso-pagination:widow-orphan; tab-stops:center 3.0in right 6.0in; font-size:12.0pt; font-family:”Times New Roman”,serif; mso-fareast-font-family:”Times New Roman”;} span.FooterChar {mso-style-name:”Footer Char”; mso-style-unhide:no; mso-style-locked:yes; mso-style-link:Footer; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-size:10.0pt; mso-ansi-font-size:10.0pt; mso-bidi-font-size:10.0pt;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; border:double windowtext 4.5pt; mso-border-top-alt:thin-thick-small-gap; mso-border-left-alt:thin-thick-small-gap; mso-border-bottom-alt:thick-thin-small-gap; mso-border-right-alt:thick-thin-small-gap; mso-border-color-alt:windowtext; mso-border-width-alt:4.5pt; padding:24.0pt 24.0pt 24.0pt 24.0pt; mso-page-border-display:first-page; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} /* List Definitions */ @list l0 {mso-list-id:990866727; mso-list-type:hybrid; mso-list-template-ids:-1922397706 67698703 67698713 67698715 67698703 67698713 67698715 67698703 67698713 67698715;} @list l0:level1 {mso-level-tab-stop:.5in; mso-level-number-position:left; text-indent:-.25in;} @list l0:level2 {mso-level-number-format:alpha-lower; mso-level-tab-stop:1.0in; mso-level-number-position:left; text-indent:-.25in;} @list l0:level3 {mso-level-number-format:roman-lower; mso-level-tab-stop:1.5in; mso-level-number-position:right; text-indent:-9.0pt;} @list l0:level5 {mso-level-number-format:alpha-lower; mso-level-tab-stop:2.5in; mso-level-number-position:left; text-indent:-.25in;} @list l0:level6 {mso-level-number-format:roman-lower; mso-level-tab-stop:3.0in; mso-level-number-position:right; text-indent:-9.0pt;} @list l0:level8 {mso-level-number-format:alpha-lower; mso-level-tab-stop:4.0in; mso-level-number-position:left; text-indent:-.25in;} @list l0:level9 {mso-level-number-format:roman-lower; mso-level-tab-stop:4.5in; mso-level-number-position:right; text-indent:-9.0pt;} ol {margin-bottom:0in;} ul {margin-bottom:0in;} –>Problem Based LearningCase Study  Baby Bryce         RT 435Advanced Clinical Cardiopulmonary Assessment Neonatal and Pediatric Assessment               Situation: Baby Bryce is a two-hour-old infant in the Neonatal Intensive Care Nursery.  He is having increasing difficulty breathing.             Baby Bryce was born two hours ago to a 17-year-old female who presented to the emergency room complaining of “stomach pains.” Brianna, his mother states that she started having “menstrual” cramps about 8 hours prior to coming into the hospital.  She then thought that she had had an “accident” with her bladder and that she had “wet” herself.  Her cramps became worse and she came into the emergency room to get checked.  She denied any possibility of being pregnant and stated that her last period was about “8 ½ months” ago.  Her cramps were rhythmic, lasting approximately 60 seconds and occurring every 2-3 minutes.  After her “accident” they had become increasingly stronger and more frequent.              In the emergency room she was found to have a fundal height of 33 cm, was 7 cm dilated and 100 percent effaced.  She was transferred to the OB ward where she delivered Baby Bryce approximately 4 hours later. Dexamethasone was given to Brianna prior to delivery.  She denies use of cigarettes, alcohol and illicit drugs.             Baby Bryce was born at 5:06 a.m. with Apgar scores of 6 and 8 at 1 and 5 minutes respectively.  He weighed 3 pounds, 8 ounces (1600 gm).  He was 17 inches long (42 cm).  A Ballard assessment scored him to be approximately 32 weeks.  He was placed in the Neonatal Intensive Care Unit. Since his birth, his respirations have become increasingly rapid.   Questions: 1.  What are the possible etiologies of difficult breathing in a neonate?    2. What are the immediate priorities?     3. What actions should be taken? Give rationale for each action.           Baby Bryce appears to be a small infant, appropriate for gestational age. Vital SignsHeart Rate: 160 beats per minute and regular. Blood pressure: 50/36 mmHg in each of the arms. Respiratory rate: 80 per minute and labored.  Audible grunting is noted. Temperature: 38.3 C (Rectal). Oxygen saturation (pulse oximetry): 86% in an Oxy-hood supplying 80% FiO2. **********Physical ExamHead: Normocephalic.  Anterior fontanelle is soft and pulsatile.  Head circumference is 30 cm. Ears: The pinae are appropriately formed and set; the external auditory canals appear patent. Eyes: Red reflex is present bilaterally.  A greasy film covers both eyes. Nose: Nasal flaring is evident and a catheter is easily passed through each nostril. Mouth: Pharynx is normal. No cleft lip or palate. Neck: Supple. There is no adenopathy or thyromegaly. Lungs: Intercostal, supraclavicular and subcostal retractions are evident.Diffuse crackles are present in all lung fields with decreased aeration noted.  CV: An S1 and S2 are apparent.  There are no obvious thrills, thrusts or heaves.  There are no murmurs, gallops or rubs.  Femoral pulses are equal and symmetric. Chest: Breast buds are 1-2 mm in size bilaterally. Abdomen: Soft. Liver is palpated 2 centimeters below the right costal margin.  Spleen and kidneys are not palpable.  There are no palpable masses.  A 3 vessel umbilical cord is noted. GU: Normal infant male.  Uncircumcised.  Testicles are descended bilaterally.  There are sparse rugae present on the scrotum.  There are no obvious hernias or hypospadias.  He has urinated since birth. Rectal: anus present.Extremities: Minimal muscle bulk is present which is appropriate for his gestational age.  His tone is appropriate for gestational age. Mild central cyanosis is noted. There are no obvious hip clicks and he has a negative Ortolani and Barlow signs. Only an anterior transverse crease is noted on inspection of the plantar surfaces of his feet.  Neuro: A positive Moro, root, palmar and plantar grasp reflexes are present. Skin: No rashes, petechiae, purpura or jaundice.  Veins are easily visible. **********Lab ResultsCBCParameter Results Reference RangeWBC 20 9-30 x103/_LRBC  6.0 4.2-5.8 x 106/_LHgb 18.0 14.0-20.0 g/dLHct 54.0 40  – 65 %Plts 295 150 – 350 x 103/_L Glucose 80  40 – 90   mg/dLCa++ 9.0  9.0 – 10.6 mg/dL Blood culture is pending. A chem panel was not ordered. Arterial Blood GasParameter Results Ref. Range(Newborn)pH 7.30 7.25 – 7.45pCO2 55  35 – 55 mmHgpO2 47  55 – 80 mmHgO2 Sat 82 93 – 100 %HCO3 26 17-24 mmol/L           Chest x-ray: Diffuse ground glass appearance to the lung fields bilaterally.  Heart size is normal.  Thymic shadow is normal.  No pneumothorax is noted.  (Normal chest x-ray follows for comparison.)          Image transcription text… Show more     Left: Supine chest radiograph demonstrates a bell shaped (square upper corners, convex sides, flaring bottom) thorax with diffuse and symmetrical ground glass infiltrates. Right: Supine chest radiograph demonstrates diffuse and symmetrical ground glass infiltrates.      Chest film of a normal term infant. Supine expiratory chest radiograph (left) and inspiratory chest radiograph (right) in the same neonate.    Questions: What is the significance of these finding?   What actions should be taken? Give rationale for each action.    Baby Bryce is intubated and given exogenous surfactant.  An umbilical artery catheter is placed.  He is started on ampicillin and gentamicin pending the blood culture results.  His initial ventilator settings include a peak inspiratory pressure of 20 cm H2O and a positive end-expiratory pressure of 4 cm water,  FiO2 of 100% and a respiratory rate of 60 breaths/min.  He is started on dextrose 10% IV fluid. Questions: 1.  Rationalize the above treatments.                         Health ScienceScienceNursingRTH 435Share Question

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