RT 240 Module 2 Assessment - Ch. 35

Which of the following is the most common type of esophageal atresia?

Esophageal atresia with a distal fistula - The most common of these malformations is esophageal atresia with a distal fistula, which comprises 85% to 90% of all tracheoesophageal fistulas.

What treatment may improve lung fluid clearance in the infant with transient tachypnea?

Frequent turning of the infant - Because the retention of lung fluid may be gravity dependent, frequent changes in the infant's position may help to speed lung fluid clearance.

What therapy has been shown to reduce the progression of lung disease in patients with cystic fibrosis?

High doses of ibuprofen - High doses of the anti-inflammatory drug ibuprofen reduce the rate of lung function loss in patients younger than 13 years.

What physiologic abnormality is believed to be the cause of persistent pulmonary hypertension of the newborn (PPHN)?

High pulmonary vascular resistance - The common denominator in PPHN is a return to fetal circulatory pathways, usually because of high PVR.

What radiographic finding is common in infants with transient tachypnea?

Hyperinflation - The chest radiographic findings, which may initially be indistinguishable from those of pneumonia, are hyperinflation, which is secondary to air trapping and perihilar streaking.

Which of the following treatments is the least useful for the treatment of RDS?

Bronchial hygiene techniques - Continuous positive airway pressure (CPAP) and positive end expiratory pressure (PEEP) are the traditional support modes used to manage RDS. Surfactant replacement therapy and high-frequency ventilation (HFV) have been added to these traditional approaches.

Which of the following therapies is considered controversial in the management of the infant with severe bronchiolitis?

Bronchodilator therapy - Bronchodilators and chest physiotherapy have not been found to be effective in routine management in patients with bronchiolitis.

What treatment is indicated for infants with transient tachypnea requiring higher FiO2?

CPAP

Which of the following diagnostic tools serves to confirm the diagnosis of congenital heart disease?

Chest X-ray

Which of the following clinical findings suggest the child with croup should be hospitalized? 1. Stridor at rest 2. Suprasternal retractions 3. Cyanosis on room air 4. Harsh breath sounds 2 and 3 1 and 2 1, 3, and 4 1, 2, 3, and 4

1, 2, 3, and 4 - If there is stridor at rest (accompanied by harsh breath sounds, suprasternal retractions, and cyanosis with breathing of room air), hospitalization is indicated.

Which of the following clinical signs are consistent with the onset of RDS? 1. Grunting 2. Retractions 3. Nasal flaring 4. Hypothermia 2 and 4 1, 2, and 3 2, 3, and 4 1 and 3

1, 2, and 3 - After tachypnea, worsening retractions, paradoxical breathing, and audible grunting are observed. Nasal flaring also may be seen. Cyanosis may or may not be present. If central cyanosis is observed, it is likely that the infant has severe hypoxemia. Certain other conditions, such as systemic hypotension, hypothermia, and poor perfusion, can mimic this aspect of RDS.

Clinical findings associated with congenital diaphragmatic hernia include which of the following? 1. Severe cyanosis 2. Decreased breath sounds 3. Displaced heart sounds 4. Hepatomegaly 1 and 3 1, 2, and 3 3 and 4 2, 3, and 4

1, 2, and 3 - Physical examination may yield the following findings: scaphoid abdomen (because the abdominal contents are in the thorax), decreased breath sounds, displaced heart sounds (because the heart is pushed away from the hernia), and severe cyanosis (from lung hypoplasia and pulmonary hypertension).

Which of the following statements are true about croup? 1. Caused by a bacterial organism 2. Most common form of airway obstruction in children aged 6 months to 6 years 3. Causes subglottic swelling and obstruction 4. Most often caused by parainfluenza virus 1 and 3 2, 3, and 4 3 and 4 1, 2, and 3

1, 2, and 3 - Croup is a viral disorder of the upper airway that normally results in subglottic swelling and obstruction. Termed laryngotracheobronchitis, viral croup is usually caused by the parainfluenza virus and is the most common form of airway obstruction in children between 6 months and 6 years of age.

Which of the following are considered contributing factors in the development of the lung that may lead to bronchopulmonary dysplasia (BPD)? 1. Hyperoxia 2. Mechanical forces 3. Inflammation 4. Maternal asthma 1 and 4 2 and 3 2, 3, and 4 1, 2, and 3

1, 2, and 3 - Factors such as hyperoxia and hypoxia, mechanical forces, pulmonary growth arrest, inflammation, nutrition, and genetics contribute to the abnormal development of the lung and lead to BPD.

Which of the following diseases are commonly associated with bronchiolitis and most likely to result in respiratory failure? 1. Infant with congenital heart failure 2. Infant with BPD 3. Child with cystic fibrosis 4. Pneumonia 2 and 4 1, 2, and 3 1 and 3 1, 3, and 4

1, 2, and 3 - Those most prone to respiratory failure as a consequence of bronchiolitis are very young and immunodeficient and have comorbidity, such as congenital heart disease, bronchopulmonary dysplasia, cystic fibrosis, or childhood asthma.

Which of the following clinical findings are usually seen in meconium aspiration syndrome? 1. Tachypnea and grunting 2. Irregular pulmonary densities on the chest film 3. Metabolic acidosis 4. Respiratory alkalosis 1 and 3 1, 2, and 3 3 and 4 2, 3, and 4

1, 2, and 3 Infants with MAS typically have gasping respirations, tachypnea, grunting, and retractions. The chest X-ray usually shows irregular pulmonary densities, which represent areas of atelectasis, and hyperlucent areas, which represent hyperinflation due to air trapping.

Which of the following are considered the primary problems seen with meconium aspiration syndrome? 1. Lung tissue damage 2. Pulmonary hypertension 3. Metabolic acidosis 4. Pulmonary obstruction 1 and 3 2 and 4 2, 3, and 4 1, 2, and 4

1, 2, and 4

Which of the following factors may stimulate pulmonary vascular spasm and cause persistent pulmonary hypertension of the newborn? 1. Hypoxemia 2. Hypoglycemia 3. Hypertension 4. Pain 3 and 4 1 and 2 1, 2, and 4 2, 3, and 4

1, 2, and 4

Which of the following clinical findings are typically seen in patients with epiglottitis? 1. High fever 2. Stridor 3. Barking cough 4. Drooling 2 and 4 1, 2, and 4 1 and 3 2, 3, and 4

1, 2, and 4 - The patient does not have a croupy bark but instead has a muffled voice.

What are the fundamental pathophysiologic events that explain PPHN? 1. Vascular spasm 2. Hypoxemia 3. Increased muscle wall thickness 4. Decreased cross-sectional area 1 and 2 2, 3, and 4 1 and 3 1, 3, and 4

1, 3, and 4

What are the major factors in the pathophysiology of RDS? 1. Qualitative surfactant deficiency 2. Increased alveolar surface area 3. Increased small airways compliance 4. Increased extrapulmonary right-to-left shunting 1 and 2 3 and 4 1, 3, and 4 2, 3, and 4

1, 3, and 4 - A qualitative decrease in surfactant increases alveolar surface tension forces, which causes alveoli to become unstable and collapse and leads to atelectasis and increased work of breathing. At the same time, the increased surface tension draws fluid from the pulmonary capillaries into the alveoli.

Which of the following clinical signs are common with croup? 1. Stridor 2. Murmur 3. Coughing 4. Cyanosis 1 and 3 2 and 3 1, 3, and 4 2, 3, and 4

1, 3, and 4 - The child typically has slow, progressive inspiratory and expiratory stridor and a barking cough. As the disease progresses, dyspnea, cyanosis, exhaustion, and agitation occur.

What percentage of births will present with meconium-stained amniotic fluid?

12%

Which of the following are associated with causing apnea in premature infants? 1. Gender 2. Intracranial lesion 3. Gastroesophageal reflux 4. Impaired oxygenation 1 and 3 1, 2, and 3 3 and 4 2, 3, and 4

2, 3, and 4

Which of the following findings are typical for infants with bronchiolitis? 1. Stridor 2. Wheezing 3. Dyspnea 4. Tachypnea 1 and 3 1, 2, and 3 3 and 4 2, 3, and 4

2, 3, and 4 - After a few days, signs of respiratory distress develop, particularly dyspnea and tachypnea. Progressive inflammation and narrowing of the airways cause inspiratory and expiratory wheezing and increase airway resistance.

Which of the following findings on the chest X-ray are typical for RDS? 1. Hyperinflation 2. Air bronchograms 3. Diffuse hazy infiltrates 4. Bilateral reticulogranular densities 1 and 3 1, 2, and 3 3 and 4 2, 3, and 4

2, 3, and 4 - Diffuse, hazy, reticulogranular densities with the presence of air bronchograms with low lung volumes are typical of RDS. The reticulogranular pattern is caused by aeration of respiratory bronchioles and collapse of the alveoli. Air bronchograms appear as aerated, dark, major bronchi surrounded by the collapsed or consolidated lung tissue.

Which statements about TTN are true? 1. TTN and neonatal pneumonia have different clinical signs. 2. The need for mechanical ventilation in TTN is rare. 3. A small number of infants with TTN eventually have persistent pulmonary hypertension. 4. Intravenous administration of antibiotics should be considered. 1 and 2 3 and 4 1, 2, and 3 2, 3, and 4

2, 3, and 4 only - Because TTN and neonatal pneumonia have similar clinical signs, intravenous administration of antibiotics should be considered for at least 3 days after appropriate culture samples are obtained. The need for mechanical ventilation is rare and probably indicates a complication. Clearing of the lungs evident on both a chest X-ray and with clinical improvement usually occurs within 24 to 48 hr. A small number of infants with TTN eventually have persistent pulmonary hypertension.

What is the maximum PIP that should be used with mechanical ventilation of larger premature infants to prevent volutrauma?

30 cm H2O - Preset tidal volume targets of 4 to 6 mL/kg should be used and peak inspiratory pressure limit should be kept less than 30 cm H2O for larger premature infants, and even lower pressure is indicated for more immature infants.

Which of the following is not associated with apnea episodes in premature infants?

Apnea lasts longer than 1 min. - Apneic spells are abnormal if (1) they last longer than 15 sec or (2) they are associated with cyanosis, pallor, hypotonia, or bradycardia.

In which of the following defects is heart transplantation an accepted option for treatment?

Hypoplastic left heart syndrome - Hypoplastic left heart syndrome has three accepted treatments: comfort care (allowing the infant to die), a palliative surgical procedure (Norwood), and transplantation.

Which of the following blood gas alteration is usually seen in meconium aspiration syndrome?

Hypoxemia and respiratory acidosis - Arterial blood gases typically show hypoxemia with mixed respiratory and metabolic acidosis.

In which infants is the surfactant administered as rescue?

Infants with diagnosis of RDS - Surfactant replacement therapy also is used as both prophylactic and rescue treatment (of infants who already have RDS).

What therapy has been shown to reduce the incidence of exacerbations in the patient with cystic fibrosis?

Inhaled DNase - The routine daily use of inhaled DNase has been shown to improve pulmonary function and reduce exacerbations in patients with CF.

A 2-year-old boy is in severe respiratory distress. The child is drooling and has labored breathing. Stridor is heard. RR is 42 breaths/min and HR is 148 beats/min. What should be done next?

Intubate - The clinical picture, particularly the age, level of distress, stridor, and drooling, suggests that this patient apparently has epiglottitis, a severe swelling of the tissue around the glottis. Given the potential for additional swelling and complete airway closure, this patient should be intubated for airway protection.

You are caring for an infant with RDS. Nasal CPAP has been used; however, the infant suddenly deteriorates and is demonstrating severe hypoxemia on an FiO2 of 0.70. What should be done next?

Intubate the infant and begin mechanical ventilation. - Mechanical ventilation with PEEP should be initiated if oxygenation does not improve with CPAP or if the patient is apneic or acidotic.

Which of the following is an example of an internal obstruction to the infant's airway?

Laryngomalacia - Internal obstruction includes common problems, such as laryngomalacia, that cause obstructive apnea.

What is the leading cause of death among patients with cystic fibrosis?

Lung disease

Which of the following factors is associated with an increase in the incidence of RDS?

Maternal diabetes - Maternal factors that impair fetal blood flow, such as abruptio placentae and maternal diabetes, also may lead to RDS.

You are taking care of an infant diagnosed with MAS with an increased work of breathing and severe respiratory acidosis. What treatment would you suggest?

Mechanical ventilation - CPAP is indicated if the primary problem is hypoxemia. By distending the small airways, CPAP can sometimes overcome the ball-valve obstruction and improve both oxygenation and ventilation. If respiratory acidosis is severe or clinical assessment indicates excessive work in breathing, mechanical ventilation should be started.

Which of the following treatments is least likely to be needed in the treatment of the child with croup?

Mechanical ventilation - Progressive worsening of the clinical signs despite treatment indicates the need for intubation and mechanical ventilation.

Which of the following is the most common defect of the abdominal wall?

Omphalocele - Large defects in the abdominal wall can cause severe respiratory compromise

What treatment usually causes improvement in the initial treatment of transient tachypnea of the newborn?

Oxygen with low FiO2 - Infants with TTN usually respond readily to a low FiO2 by infant oxygen hood or nasal cannula.

Which of the following infant characteristics is associated with an increased risk of SIDS?

Preterm birth - An infant who dies of SIDS typically is a preterm African-American boy born to a poor mother younger than 20 years who received inadequate prenatal care.

Which of the following therapies has little effect on long-term outcome such as mortality and duration of oxygen therapy in infants with BPD?

Steroids - Diuretics are given as needed to decrease pulmonary edema; antibiotics are given to manage existing pulmonary infection. Bronchodilator therapy may help decrease airway resistance but should be used cautiously in patients with floppy airways. Steroid therapy with dexamethasone can produce substantial short-term improvement in lung function, often allowing rapid weaning from ventilatory support. However, steroid therapy has little effect on long-term outcome such as mortality and duration of O2 therapy.

Which of the following findings is not associated with gastroesophageal reflux (GER) disease?

Syncope - Respiratory problems caused by gastroesophageal reflux include reactive airways disease, aspiration pneumonia, laryngospasm, stridor, chronic cough, choking spells, and apnea.

What is the first clinical sign of RDS in the newborn infant?

Tachypnea

Which of the following is the most common radiographic finding that suggests the presence of epiglottitis?

Thumb sign - Lateral neck radiographic results indicate the epiglottis is markedly thickened and flattened (thumb sign).

Which of the following is the most likely diagnosis in the newborn with severe cyanosis at birth?

Transposition of the great vessels

What modality is believed to be the cause of a decrease in the reported incidence of epiglottitis over the past decade?

Vaccine

What is associated with ball-valve obstruction in meconium aspiration syndrome?

Volutrauma - Ball-valve obstruction causes air trapping and can lead to volutrauma