The nurse observes respiratory distress in an infant with phrenic nerve palsy

An infant is noted to have severe bruises after birth, and a nurse observes that the infant is not using his right arm. The birth was noted to be traumatic, and the nurse calls you to evaluate the infant. Birth injuries are injuries that occur during the birth process. The incidence is ∽6–8 per 1000 live births (higher rates for infants >4500 g). Birth injuries occur from both vaginal and cesarean deliveries. Infants delivered by cesarean section are at risk for different types of birth trauma than infants delivered vaginally. Infants delivered by cesarean have a decreased risk of all birth trauma due to the decreased risk of clavicle fractures, brachial plexus, and scalp injuries.

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II. IMMEDIATE QUESTIONS

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1. Are there any risk factors for a birth injury? Certain factors predispose the infant to birth injuries. These include fetal macrosomia, prima gravida, small maternal stature, prolonged or very rapid labor, precipitous delivery, difficult fetal extraction, abnormal presentation (especially breech), vaginal breech delivery, cephalopelvic disproportion, maternal pelvic abnormalities, oligohydramnios, nuchal cord, very low birthweight infant, very large fetal size, fetal anomalies (osteogenesis imperfecta), use of forceps or vacuum extraction, and prematurity.

2. Is the injury so serious that it requires immediate attention? The majority of birth injuries are not serious and do not require urgent treatment. Significant injuries requiring immediate intervention, such as abdominal organ injuries that present as shock and require surgery, need to be identified early.

3. Was forceps or vacuum extraction used during the delivery? Studies suggest that the use of mid-forceps and vacuum extraction may increase the infant's risk of fractures and paralysis.

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III. DIFFERENTIAL DIAGNOSIS (BASED ON SITE OF INJURY)

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1. Skin

   1. Petechiae. Small (<3 mm) bruises that do not blanch on pressure. In birth trauma, petechiae are usually localized (eg, on the head, neck, upper chest area, and lower back). There is no associated bleeding, and no new lesions appear. If petechiae are diffuse, suspect thrombocytopenia or other systemic disease. If there is bleeding from venipuncture sites, suspect coagulation disorders or other diseases.

   2. Ecchymosis. A >1 cm bruise beneath the skin. Bruising can occur after a traumatic delivery, especially when labor is rapid or the infant is premature.

   3. Abrasions or lacerations. These can occur secondary to the use of a scalpel during a cesarean delivery. They usually occur on the buttocks, scalp, or thigh. Sometimes suturing is necessary.

   4. Forceps injury. Frequently, reddish linear marks are seen across both sides of the face.

   5. Scalp electrode injury. The site of insertion of the scalp electrode can sometimes become infected (1% of cases) and in premature infants can rarely cause severe bleeding.

   6. Subcutaneous fat necrosis. Typically involves the shoulders and the buttocks with a well-circumscribed lesion of the skin and underlying tissue. It usually appears between 6 and 10 days of age. Lesion size is 1–10 cm, it can be irregular and hard, and the overlying skin can be purple or colorless. (See Chapter 75 and Plate 9.)

2. Head

   1. Soft tissue injury. Bruising and petechiae of the soft tissue can occur.

   2. Extracranial injury. See Chapter 6, Figure 6–1.

      1. Caput succedaneum. This is an area of generalized edema over the presenting part of the scalp during a vertex delivery and is associated with bruising and petechiae. It crosses the midline of the skull and suture lines. The bleeding is external to the periosteum. Hyperbilirubinemia rarely develops. A vacuum-induced caput occurs during a delivery using a vacuum device.

      2. Cephalhematoma. Incidence is 1.5–2.5% of all deliveries. This is caused by bleeding that occurs below the periosteum overlying one cranial bone (usually the parietal bone). There is no crossing of the suture lines. The overlying scalp is not discolored, and the swelling sometimes takes days to become apparent. The incidence of an associated skull fracture is 5% in unilateral lesions and 18% in bilateral lesions and is most often a linear fracture. Hyperbilirubinemia (sometimes significant if the lesion is extensive) may develop. Other complications such as meningitis and osteomyelitis can occur.

      3. Subgaleal hemorrhage (also called subaponeurotic hemorrhage). A collection of blood in the soft tissue space under the aponeurosis but above the periosteum of the skull. Usually caused by forceps or vacuum with traction on the emissary veins. Diffuse swelling of the soft tissue, often spreading toward the neck and behind the ears, can be seen. Periorbital swelling is also evident. Associated signs include severe blood loss (potential to hold more than half the total blood volume), shock, anemia, hypotonia, seizures, and pallor. Rarely, a fatal complication of a traumatic birth.

   3. Intracranial injury. Most common subdural hemorrhage (73%), then subarachnoid (20%), intracerebral (20%), intraventricular, then epidural hemorrhage. (See also Chapter 104.)

      1. Subdural hemorrhage. Blood between the arachnoid membrane and dura. Infants present shortly after birth with stupor, seizures, a full fontanelle, unresponsive pupils, and coma.

      2. Subarachnoid hemorrhage. Blood between the arachnoid membrane and pia mater. Usually asymptomatic, but seizures and other complications such as high bilirubin can be seen.

      3. Intraparenchymal hemorrhage

         1. Intracerebellar hematoma/cerebellar hemorrhage. Associated with traumatic delivery and can present with apnea, unexplained motor agitation in preterm infants, bulging fontanel, and decreased hematocrit.

         2. Intracerebral hemorrhage. This can occur from cranial birth trauma but is more commonly associated with other causes.

      4. Intraventricular hemorrhage. Bleeding into the ventricular system; occurs secondary to prematurity. In the term infant it occurs secondary to birth trauma or asphyxia. Presents with apnea, lethargy, cyanosis, seizures, weak suck, and high-pitched cry.

      5. Epidural hemorrhage. Blood between the skull and outside of the dura; very rare and one cause is the infant being dropped during delivery. Symptoms are similar to those of subdural hemorrhage; diagnosed by computed tomography (CT) or magnetic resonance imaging (MRI). Clinical manifestations are usually delayed, and it is often associated with skull fracture and cephalhematoma.

      6. Contusion bruise (cerebral and cerebellum) of the brain. Presents with nonspecific neurologic dysfunction. CT shows punctate hemorrhages.

   4. Skull fracture. These bone injuries are uncommon in neonates; most are linear and are associated with a cephalhematoma. Fractures at the base of the skull may result in shock. Occipital fractures can be associated with breech deliveries.

      1. Linear fracture. A break that transverses the full thickness of the skull, is straight, and has no displacement. Usually no therapy is required.

      2. Depressed fracture. A depressed fracture (ping-pong fracture) of the skull is caused by the bone (most commonly the parietal) being displaced inward. Depressed fractures are often visible and can result in seizures. It occurs from birth trauma but a congenital depressed fracture of the skull can also occur prenatally or in the absence of trauma.

      3. Occipital osteodiastasis. Rare because of improved obstetric techniques. Traumatic separation of the cartilaginous joint between the squamous and lateral portion of the occipital bone that results in a posterior fossa subdural hemorrhage associated with laceration of the cerebellum. There are 3 types: classic, fatal form, and less severe variant compatible with survival.

3. Facial

   1. Fractures of the nose, mandible, maxilla, lacrimal bones, and septal cartilage. These can often present as respiratory distress or feeding problems and require treatment. Urgent plastic surgery consultation is recommended.

   2. Dislocations of the facial bones. Nasal septal dislocation (the most common facial injury) can occur and presents as stridor and cyanosis. Facial bone and mandibular fractures can occur.

   3. Facial nerve palsy. This is the most common cranial nerve (cranial nerve VII) injury secondary to birth trauma. It is not increased in deliveries involving forceps, as previously believed. The nerve is injured at the point where it emerges from the stylomastoid foramen.

      1. Central paralysis. Involves the lower half or two-thirds of the contralateral side of the face. On the paralyzed side, the nasolabial fold is obliterated, the corner of the mouth droops, and the skin is smooth and full. When the infant cries, the wrinkles are deeper on the normal side, and the mouth is drawn to the normal side.

      2. Peripheral paralysis. Involves the entire side of the face. At rest, the infant has an open eye on the affected side. When the infant cries, the findings are similar to those with central paralysis.

4. Eye

   1. Eyelids. Edema and bruising can occur. Swollen eyelids should be forced open to examine the eyeball. Laceration of the eyelid can also occur.

   2. Orbit fracture. Rarely occurs. Immediate ophthalmologic evaluation is necessary if disturbances of the extraocular muscle movements and exophthalmos are evident. Severe injuries may result in death.

   3. Horner syndrome. Due to impaired sympathetic outflow with signs such as miosis, partial ptosis, enophthalmos, and anhidrosis of the ipsilateral side of the face. Delayed pigmentation of the ipsilateral iris can be seen as the child grows.

   4. Subconjunctival hemorrhage. A common finding that resolves without treatment.

   5. Cornea. Haziness can be secondary to edema or use of eye prophylaxis. With persistent haziness, suspect rupture of Descemet membrane.

   6. External ocular muscle injuries involving the third, fourth, and sixth cranial nerves.

   7. Optic nerve injury. Vision may be affected.

   8. Intraocular hemorrhage

      1. Retinal hemorrhage. Most commonly a flame-shaped or streak hemorrhage found near the optic disk. A subdural hemorrhage can cause preretinal and intraretinal hemorrhages.

      2. Hyphemas. Gross blood is seen in the anterior chamber.

      3. Vitreous hemorrhage. Indicated by floaters, absent red reflex, and blood pigment seen on slit-lamp examination by the ophthalmologist.

5. Ear. Ear injuries (abrasions, bruising, hematomas, avulsion, or laceration of the auricle) can occur, often due to forceps placed near the ears.

6. Nose. Nasal deformity (deformity of the nasal pyramid, soft tissue, and septum) can occur. It is increased in prolonged delivery, increased head circumference, and vaginal delivery. Fracture and dislocation can occur, and infants may have respiratory distress.

7. Vocal cord injuries. Although rare, they can occur as a result of excessive traction on the head during delivery and are caused by an injury to the recurrent laryngeal branch of the vagus nerve. Often associated with forceps in a difficult delivery, they can result in bilateral or unilateral vocal cord paralysis and may cause acute respiratory compromise.

   1. Unilateral paralysis. Involves the recurrent laryngeal branch of one of the vagus nerves in the neck. Clinically, hoarseness (weak cry, abnormal voice) and mild to moderate stridor with inspiration are seen. Unilateral vocal cord paralysis is usually left sided because of the nerves' longer course and position for injury.

   2. Bilateral paralysis. Caused by trauma to both recurrent laryngeal nerves. Symptoms at birth include respiratory distress, stridor, and cyanosis.

8. Neck shoulder and chest injuries

   1. Shoulder dystocia. Occurs when the head is delivered and the shoulder gets stuck during delivery. Trauma to the neck can occur when the baby is delivered. The most common injury is brachial plexus injury, but the clavicle can be broken, or cord compression can occur.

   2. Clavicular fracture. The most common bone fracture during delivery. If the fracture is complete, symptoms involve decreased or absent movement of the arm, gross deformity of the clavicle, pain response on palpation, localized crepitus, and an absent or asymmetric Moro reflex. Green-stick fracture usually presents with no symptoms, and the diagnosis is made because of callus formation at 7–10 days.

   3. Rib fractures. Very rare.

   4. Brachial palsy. Usually secondary to prolonged delivery of a macrosomic infant. The spinal roots of the fifth cervical through the first thoracic spinal nerves (brachial plexus) are injured during birth. This is usually unilateral and occurs twice as often on the right as the left. Obstetrical shoulder dystocia training was associated with a lower incidence of brachial plexus injury. (See Chapter 6.) There are 3 different presentations.

      1. Duchenne-Erb palsy. This involves the upper arm and is the most common type (∽90% of cases). The fifth and sixth cervical roots are affected, and the arm is adducted and internally rotated. Moro reflex is absent (sometimes it can be asymmetric or weakened), but the grasp reflex is intact.

      2. Klumpke palsy. This involves the lower arm because the seventh and eighth cervical and first thoracic roots are injured; it is rare (2.5% of cases). The hand is paralyzed, the wrist does not move, and the grasp reflex is absent (ie, dropped hand). Cyanosis and edema of the hand can also occur. An ipsilateral Horner syndrome (ptosis, miosis, and enophthalmos) can be seen because of injury involving the cervical sympathetic fibers of the first thoracic root. Phrenic nerve paralysis with Klumpke palsy is evident.

      3. Entire arm (global or total brachial plexus) paralysis. The entire brachial plexus is damaged. The patient has a flaccid arm, hanging limply with no reflexes.

   5. Phrenic nerve paralysis. Difficult breech delivery can rarely cause diaphragmatic paralysis and usually occurs along with upper brachial nerve palsy (75% of cases). It is associated with cyanosis, tachypnea, irregular respirations, and thoracic breathing with no bulging of the abdomen.

   6. Sternocleidomastoid muscle (SCM) injury (muscular or congenital torticollis). A well-circumscribed, immobile mass in the mid-portion of the SCM that enlarges, regresses, and disappears. This results in a transient torticollis after birth. The head tilts toward the involved side, the chin is elevated and rotated, and the patient cannot move the head into normal position.

9. Spinal cord injuries. Rare and are caused by lateral or longitudinal stretching force of the neck or hyperextension or torsion of the fetal neck. Symptoms vary, depending on the location of the injury. Such injuries usually occur with breech deliveries or use of forceps. They can involve meningeal damage with epidural hemorrhage, spinal artery occlusion, vertebral artery injuries and occlusion, laceration of the spinal nerve roots and bruising, and laceration or complete transection of the cord. The higher the injury, the greater is the risk of respiratory problems.

   1. Infants with a high cervical lesion. Usually have severe respiratory depression with paralysis at birth. Mortality is high.

   2. Upper or mid cervical lesions. Usually present without symptoms but can have hypotonia. Mortality is high.

   3. Lesions in the seventh cervical to first thoracic roots. Present with paraplegia and urinary and respiratory problems.

   4. Partial spinal cord injuries. On neurologic examination, these infants have signs of spasticity.

10. Abdominal organ injuries (uncommon). These injuries should be suspected with shock, increasing abdominal circumference, anemia, and irritability. These infants can be asymptomatic for hours and then deteriorate acutely. Risk factors for these include macrosomia and breech presentation. Intraperitoneal bleed needs to be ruled out in every infant who presents with shock and abdominal distension. Paracentesis is essential.

    1. Liver hematoma/rupture. The liver is the most common organ affected. Subcapsular hematomas are the most common lesion and are usually not easily diagnosed (subtle signs of blood loss include onset of jaundice, tachypnea, and poor feeding). Rupture of the hematoma presents with sudden circulatory collapse (a hematoma ruptures through the capsule).

    2. Splenic hematoma/rupture. Signs are similar to rupture of the liver; blood loss and hemoperitoneum may be seen. Less frequent than hepatic injury.

    3. Adrenal hemorrhage. Usually right sided and unilateral. Symptoms include fever, tachypnea, flank mass, pallor, cyanosis, poor feeding, shock, vomiting, and diarrhea.

    4. Renal/kidney trauma. Similar to the other organ injuries with ascites, flank mass, and gross hematuria.

11. Extremity injuries. See also Chapter 115.

    1. Fractured humerus. The second most common fracture during birth trauma. The arm is immobile, with tenderness and crepitation on palpation. Moro reflex is absent on the affected side.

    2. Fractured femur. May occur secondary to breech delivery. Infants with congenital hypotonia are at risk. Deformity is usually obvious; the affected leg does not move, and there is pain with assisted movement.

    3. Fractured radius. Rare.

    4. Epiphyseal displacement/dislocation. Rarely seen, this usually involves the radial head but can also involve the humeral or femoral epiphysis. Examination reveals adduction, internal rotation of the affected arm, and poor Moro reflex. Palpate lateral and posterior displacement of the radial head.

    5. Sciatic nerve palsy. Rare and can occur in breech deliveries. Prolonged labor and a forceful extraction of the leg is usually obtained from the history. Complete or partial paralysis can occur.

    6. Radial nerve palsy (rare). Infants present with absent wrist and digital extension, but good shoulder and elbow function. Ecchymosis and fat necrosis may support a compression injury during labor.

12. Genital injuries

    1. Edema, bruising, and hematoma of the scrotum and penis. Occur especially in large infants and with breech deliveries. Injury usually does not affect micturition.

    2. Testicular and epididymal injury. Findings are scrotal swelling, with the infant experiencing vomiting and irritability. A hematocele can form if the tunica vaginalis testis is injured; the scrotum will not transilluminate. Scrotal rupture is only in case reports.

13. Umbilical cord rupture. This can occur from trauma from an operative vaginal delivery (forceps or vacuum device used). Hemorrhage with bradycardia and respiratory distress can occur.

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IV. DATABASE

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1. Physical examination. Details on the physical examination of the newborn are found in Chapter 6.

   1. Skin. Look for petechiae, bruising, and any lacerations. Check the side of the face for forceps marks. Look for and palpate any area that looks like fat necrosis.

   2. Head. Carefully examine the head for any evidence of a caput succedaneum, cephalhematoma, subgaleal hemorrhage, or fracture. Check to see whether the suture lines are crossed (differentiates between the caput succedaneum and cephalhematoma). Depressed skull fractures are obvious; others may require radiologic studies.

   3. Face. Examine the face at rest and during crying to look for any facial asymmetry (nerve palsy). Check for any signs of respiratory distress (stridor or cyanosis).

   4. Eyes. Examine the eyeball and the eyelid. Make sure that extraocular muscle movements are normal. Check for the red reflex.

   5. Ears. Examine the front and back of the ear, looking for lacerations, swelling, and hematomas.

   6. Vocal cords. Signs may include high-pitched cry or stridor. If injury is suspected, examine the vocal cords by direct laryngoscopy or use a flexible fiber optic laryngoscope.

   7. Neck and shoulder injuries. Carefully examine the neck and the shoulder. Check Moro and grasp reflexes. Examine the arm to see whether movement is normal. Check respirations, and note any thoracic breathing. Make sure the head rests in a normal position and is not tilted.

   8. Spinal cord. A careful and thorough neurologic examination should be done.

   9. Abdomen. Examine the abdomen, and check for ascites, masses, and increase in size.

   10. Extremities. Observe for movement and deformity.

   11. Genitalia. Examine the testes and the penis in males; transilluminate the scrotum.

2. Laboratory studies based on site of trauma

   1. Skin

      1. Platelet count. A normal platelet count excludes neonatal thrombocytopenia.

      2. Serum bilirubin test. Hyperbilirubinemia may result from reabsorption of blood from extensive ecchymoses.

      3. Serum hematocrit. Anemia may result from severe ecchymoses.

   2. Head

      1. Hematocrit. Blood loss can occur, sometimes requiring transfusions, especially in subgaleal hemorrhage.

      2. Serum bilirubin. Significant hyperbilirubinemia may result from cephalohematoma.

   3. Face. Arterial blood gas may be indicated in those infants with respiratory distress. Nerve excitability or conduction tests are recommended if there is no improvement in the facial nerve palsy after 3–4 days.

   4. Eyes, ears, or vocal cords. No laboratory tests are usually required.

   5. Neck and shoulder. Arterial blood gas helps diagnose hypoxia associated with phrenic nerve paralysis.

   6. Spinal cord. The usual laboratory tests required for respiratory depression and shock, if indicated.

   7. Abdomen. Obtain hematocrit to rule out anemia and blood loss and urine dipstick to check for hematuria. Consider abdominal paracentesis with fluid sent to the laboratory for cell count with differential.

   8. Extremities and genitalia. No laboratory tests are usually needed.

3. Imaging and other studies

   1. Head. Skull radiographs should be obtained to rule out the possibility of skull fractures. A CT scan can also be obtained and can be useful in the diagnosis of an intracranial hemorrhage.

   2. Face. Radiographs and a cranial CT scan to help diagnose facial fractures.

   3. Eyes. Radiographs, to rule out orbit fracture, may be indicated.

   4. Neck and shoulder

      1. Radiograph of the clavicle. Necessary for confirmation of the diagnosis of fracture.

      2. Radiograph of the chest for phrenic nerve paralysis. Shows an elevated diaphragm.

      3. Fluoroscopy. Reveals elevation of the affected side and descent of the normal side on inspiration with phrenic nerve impairment. Opposite movements occur with expiration.

      4. Ultrasound of the diaphragm. Shows abnormal motion on the affected side.

      5. MRI of the neck and spine. Shows nerve root avulsion.

      6. Electroencephalogram. Reveals the extent of the denervation weeks after the injury.

   5. Spinal cord

      1. Cervical and thoracic spine radiographs. These should be obtained.

      2. MRI. Most reliable method for diagnosing spinal cord injuries.

   6. Abdomen. Abdominal ultrasound usually diagnoses liver and splenic rupture, adrenal hemorrhage, and kidney damage. An abdominal radiograph may reveal a stomach bubble displaced medially in splenic rupture.

   7. Extremities. A radiograph of the extremities confirms the diagnosis.

   8. Genitalia. Ultrasonography is diagnostic.

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V. PLAN

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1. Skin

   1. Petechiae. No specific treatment is necessary, as traumatic petechiae usually fade in 2–3 days.

   2. Subcutaneous fat necrosis. The lesions require minimal pressure at the affected site and observation only. They disappear within a couple of months but may calcify. Closely monitor the first 6 weeks for symptomatic hypercalcemia (vomiting, fever, and weight loss with high serum calcium), which can occur. This can usually be treated with intravenous hydration, furosemide, and hydrocortisone therapy.

   3. Ecchymoses. No specific treatment is necessary because they usually resolve within 1 week. Monitor for hyperbilirubinemia (reabsorption of blood from a bruised area), anemia (blood loss from bruising), and hyperkalemia.

   4. Lacerations and abrasions. If superficial, the edges may be held together with butterfly adhesive strips. If deeper, they should be sutured with 7–0 nylon. Healing is usually rapid. Observe for infections, especially a scalp lesion and caput succedaneum.

2. Head

   1. Caput succedaneum. No specific treatment is necessary, as it resolves within several days.

   2. Cephalhematoma. Usually no treatment is necessary, and it resolves anywhere between 2 weeks and 3 months. CT or skull radiography may be necessary if neurologic symptoms or depressed skull fracture are present. In some cases, blood loss and hyperbilirubinemia can occur.

   3. Subgaleal hemorrhage. If hypovolemic shock develops, it requires immediate treatment. Surgery is done if the bleeding does not subside. Death may occur. Look for coagulopathies and treat as needed.

   4. Intracranial hemorrhage. Circulatory and ventilatory support are indicated in deteriorating conditions. (See also Chapter 104.)

      1. Subarachnoid. Resolution usually occurs without treatment.

      2. Epidural. Prompt surgical evacuation for large bleeds. Prognosis is good with early treatment.

      3. Subdural. Subdural taps are indicated to drain a large hematoma.

   5. Skull fracture. Linear fractures do not require treatment. Depressed skull fractures can be treated conservatively or surgically. For a simple depressed skull fracture nonsurgical management is recommended. For larger and deeper depressions, vacuum extraction or surgery is required.

3. Face

   1. Facial nerve injury. No specific therapy is necessary. Full resolution usually occurs within a few months. Neurology consult should be obtained if no improvement in 2–3 weeks.

      1. Complete peripheral paralysis. Cover the exposed eye with an eye patch and instill synthetic tears (1% methylcellulose drops) every 4 hours. This will prevent irritation from the dryness.

      2. Electrodiagnostic testing. May be beneficial in predicting recovery.

      3. Surgery. May be necessary in severe cases.

   2. Fractures. Maxilla, lacrimal, mandible, and nose fractures require immediate evaluation. An oral airway is required, and surgical consultation is needed. The fractures must be reduced and fixated. Plastic surgery consultation recommended.

4. Eyes

   1. Eyelids. Edema and bruising usually resolve within 1 week. Laceration of the eyelid may require microsurgery.

   2. Orbit fracture. Immediate ophthalmologic consultation is required.

   3. Horner syndrome. No treatment is necessary, and resolution usually occurs.

   4. Subconjunctival hemorrhage. No treatment is necessary because the blood is usually absorbed within 1–2 weeks.

   5. Cornea. Haziness disappears usually within 2 weeks. If persistent and if rupture of Descemet membrane has occurred, then a white opacity of the cornea will occur. This is usually permanent, and ophthalmologic input is essential.

   6. Intraocular hemorrhage

      1. Retinal hemorrhage. Usually disappears within 1 week. No treatment is necessary.

      2. Hyphema. Usually resolves without treatment within 1 week.

      3. Vitreous hemorrhage. If resolution does not occur within 1 year, surgery must be considered.

5. Ears

   1. Abrasions and ecchymoses. These injuries are usually mild and require no treatment, except for keeping the area clean. They resolve spontaneously.

   2. Hematomas. Incision and evacuation may be indicated.

   3. Avulsion of the auricle. Surgical consultation is required if cartilage is involved.

   4. Laceration of the ear. Most of these can be sutured with 7–0 nylon sutures.

6. Vocal cords

   1. Unilateral paralysis. Observe these infants closely. Keeping them quiet and giving small, frequent feedings decreases the risk of aspiration. This condition usually resolves within 4–6 weeks.

   2. Bilateral paralysis. Intubation is required if there is airway obstruction. Ear, nose, and throat consultation and tracheostomy are usually required. The prognosis is variable.

7. Neck and shoulder

   1. Clavicular fracture. Immobilization (pinning the infants sleeve to the shirt) helps to decrease pain, and the prognosis is excellent. Pain medication can be given.

   2. Brachial palsy. Immobilization and physical therapy to prevent contractures until recovery of the brachial plexus. Recovery depends on the extent of the lesions and is usually good but may take many months. In Erb-Duchenne paralysis, one can see improvement in 2 weeks, and recovery is usually complete by 18 months. In Klumpke paralysis, prognosis is poorer and sometimes never complete. Muscle atrophy and contractures can occur. Orthopedic consultation is recommended early on.

   3. Phrenic nerve paralysis. Treatment is usually supportive and nonspecific, and the prognosis is usually good. Some infants may require continuous positive airway pressure or mechanical ventilation. Most infants recover in 1–3 months.

   4. Sternocleidomastoid muscle injury. Most recover spontaneously. Passive exercise may be indicated, and appropriate positioning of the infant is recommended. If it is not resolved within 1 year, surgery should be considered.

8. Spinal cord. Prognosis depends on the level and severity of the injury. Most infants with a severe spinal cord injury do not survive. Treatment is supportive, and some require intubation for respiratory problems. Specific therapy needs to be directed at the bladder, bowel, and skin because these present as ongoing problems.

9. Abdomen. Surgical consultation is needed, and the prognosis for all of these depend on early recognition and treatment. Early management strategies that increase survival include volume replacement and identifying and correcting coagulation disorders.

   1. Liver rupture. Transfusion, laparotomy with evacuation of hematomas, and repair of any laceration.

   2. Splenic rupture. Volume replacement with transfusion of whole blood and correction of coagulation disorders. Exploratory laparotomy, with preservation of the spleen if possible.

   3. Adrenal hemorrhage. Management is supportive, with blood transfusion and intravenous steroids usually the only treatment.

   4. Kidney damage. Use supportive measures. Surgery may be necessary if severe.

10. Extremities

    1. Fractured humerus. Obtain an orthopedic consultation. Immobilize the arm for usually 2 weeks. Displaced fractures may require closed reduction and casting. The prognosis is excellent.

    2. Fractured femur. Obtain an orthopedic consultation. Splinting is necessary. Displaced fractures may require closed reduction and casting. The prognosis is excellent.

    3. Epiphyseal displacement/dislocation. Treatment is immediate reduction with immobilization of the arm for 8–10 days.

11. Genitalia

    1. Edema and bruising. These usually resolve within 4–5 days, and no treatment is necessary.

    2. Testicular injury. Urgent urologic or pediatric surgical consultation is necessary, as rupture may require surgical repair.

    3. Hematocele. Elevate the scrotum with cold packs. Resolution occurs without other treatment, unless there is a severe underlying testicular injury.

       Which conditions is the nurse alert for in a preterm infant with respiratory distress?

       Flaring nostrils. Rapid breathing. Grunting sounds with breathing. Ribs and breastbone pulling in when the baby breathes (chest retractions)

       Which is a priority nursing intervention when providing care for a high risk infant?

       With every newborn contact, respiratory evaluation is necessary because this is the highest priority in newborn care.

       What is the main factor that is responsible for respiratory distress syndrome in newborns quizlet?

       Respiratory distress syndrome is a breathing disorder that mainly occurs in premature newborns. This is due to the fact that premature infants have immature lungs that aren't able to produce enough surfactant, which coats the insides of the lungs to keep them from collapsing.

       Which intervention does the nurse implement while providing care for an infant with neonatal abstinence syndrome?

       Standard of care interventions include decreasing external stimulation, holding, nonnutritive sucking, swaddling, pressure/rubbing, and rocking. These interventions meet the goals of nonpharmacologic interventions, which are to facilitate parental attachment and decrease external stimuli.