Pediatric Examination and Board Review (210 page)

(A) 34

(B) 36

(C) 38

(D) 40

(E) gestational age is not a consideration

2.
The guidelines for an early discharge also specify that the newborn must have a birthweight of

(A) at least 1800 g

(B) at least 2000 g

(C) at least 2500 g

(D) at least 3000 g

(E) a birthweight 1800 g or more and appropriate for gestational age (AGA)

3.
All of the following information would be needed for assessment of discharge readiness for this baby except

(A) a serum bilirubin either normal or unlikely to be on a trajectory requiring phototherapy

(B) feeding ability

(C) follow-up care arrangements in place

(D) demonstrated hemostasis after circumcision

(E) all of the above would be needed information

4.
What would be considered the most reliable information for establishing the gestational age in this small baby?

(A) Ballard score

(B) prenatal ultrasound before 18 weeks’ gestation

(C) calculation based on last menstrual period

(D) bone age, left wrist

(E) bone age, left foot

5.
After your assessment of risk in sending this baby home at 40 hours, what would be the most appropriate thing to tell the parents?

(A) they should watch for jaundice and call with any concerns

(B) they should observe his weight

(C) you are concerned enough not to send the baby home

(D) they should follow up in 3 days or less with the pediatrician

(E) they should watch for jaundice, keep the child in front of a sunny window, and call with any concerns

6.
The parents of a term normal birthweight girl ask to be discharged at 12 hours. The mother is an experienced breast feeder and feedings are going fairly well. The baby has not passed any stool. You tell them

(A) your admission examination is normal so the baby can go home

(B) you want the baby to have passed meconium before you write an order for discharge

(C) the baby has no jaundice and therefore can go home

(D) the child cannot be discharged before 36 hours of age

(E) if the discharge examination is normal, she can go home

7.
For a baby to be discharged, it is important that

(A) the baby has completed at least two successful feedings

(B) the baby has coordinated suck and swallow

(C) during breastfeeding the baby latches to the breast without pain to the mother

(D) the baby has urinated and passed at least one stool

(E) all of the above

8.
All infants having a short hospital stay must be examined by experienced health personnel within

(A) 24 hours of discharge

(B) 48 hours of discharge

(C) 72 hours of discharge

(D) within a week of discharge

(E) within the first 2 weeks of life

9.
Ductal-dependent cardiac lesions may not be apparent until

(A) 2 hours of life

(B) 6 hours of life

(C) 12 hours of life

(D) 24 hours of life

(E) more than 24 hours of life

10.
Contraindications to early discharge are

(A) low birthweight

(B) congenital anomalies

(C) prematurity

(D) teenage mother

(E) all of the above

11.
Before early discharge, cord blood type and a Coombs test should be performed on

(A) all babies

(B) babies whose mothers are group O

(C) all babies with a family history of jaundice

(D) babies whose mothers are Rh negative

(E) B and D

ANSWERS

1.
(C)
Premature babies younger than 38 weeks of gestation can have feeding problems and temperature instability. They should be observed for more than 48 hours to establish oral feedings, monitor bilirubin, and monitor temperature stability in an open crib.

2.
(E)
Babies that are SGA and babies lighter than 1800 g have problems maintaining their temperature in an open crib.

3.
(E)
Babies at discharge should be feeding well, have a serum bilirubin level in the low-risk zone of the Bhutani nomogram, should have achieved bleeding hemostasis postcircumcision, and have a follow-up appointment.

4.
(B)
The most accurate assessment of gestational age uses the first trimester ultrasound measurement of crown-rump length.

5.
(C)

6.
(B)
Ninety percent of newborn babies pass meconium in the first 24 hours of life. Babies should be observed long enough to make sure feedings are established, the baby has passed urine and stool, and the bilirubin is in the range of the Bhutani nomogram low-risk zone.

7.
(E)

8.
(B)
The AAP recommends a follow-up visit within 48 hours after early discharge.

9.
(E)

10.
(E)
Low-birthweight babies, premature babies, and babies with congenital abnormalities may have feeding problems, temperature instability, hyperbilirubinemia, or metabolic problems like hypoglycemia or hypocalcemia. They should not be discharged early. Teenage mothers should be evaluated by a social worker to make sure there is an adequate support system at home.

11.
(E)
Babies born to O-positive mothers or Rhnegative mothers have the possibility of blood group incompatibility if the baby’s blood group is A, B, or the baby is Rh positive. Therefore, cord blood type determination and a direct Coombs test should be done in mothers with blood group O or Rh negative.

S
UGGESTED
R
EADING

American Academy of Pediatrics. Committee on fetus and newborn. Hospital stay for healthy term newborns.
Pediatrics.
1995;96:788-790.

American Academy of Pediatrics: Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.
Pediatrics.
2003;114:297-316

CASE 120: A TERM NEONATE REQUIRES ROUTINE CARE IN THE NURSERY

A full-term 3500-g baby girl is born after a normal vaginal delivery following 4 hours of labor with rupture of membranes. The mother brought the baby for all of the scheduled prenatal visits and had no complications. The family history is noncontributory.

On examination the baby has normal vital signs and is pink and vigorous.

SELECT THE ONE BEST ANSWER

1.
Which routine procedures should be done in the birth room?

(A) administer hepatitis B vaccine

(B) administer vitamin K IM

(C) administer vitamin K orally

(D) apply prophylactic ophthalmic antibiotic ointment

(E) B and D

2.
Upon admission to the nursery, what other routine procedures should be done?

(A) glucose screen

(B) hematocrit screen

(C) glucose water feeding

(D) A, B, and C

(E) none of the above

3.
If the mother’s lower vaginal and rectal culture results for GBS were unknown, what would you do for the baby if no prophylactic penicillin had been given to the mother intrapartum?

(A) start oral amoxicillin

(B) draw a blood culture, a CBC, and start IV penicillin

(C) do an LP

(D) observe without intervention

(E) draw a blood culture and a CBC but do not start antibiotics

4.
If the mother is GBS positive and received prophylactic intrapartum penicillin for more than 4 hours before delivery, what would be your best course?

(A) obtain a blood culture and observe