The 5-day-old 38-week-gestation neonate was born to a 25-year-old primigravida woman after a pregnancy and vacuum-assisted delivery complicated by gestational diabetes, large for gestational age fetus, and shoulder dystocia. The neonate required vigorous stimulation and positive pressure ventilation. Apgar scores were 3 and 8 at 1 and 5 minutes of life. At the pediatrician’s appointment after discharge, the neonate is found to have a large bruise at the back of the head that was sustained during birth and eyes glued shut with yellow, mucopurulent discharge. A gram stain of the drainage reveals gram-negative cocci in pairs. The mother states, “No matter what I do, it keeps coming back. I’ve used warm compresses and washed it away.” Additionally, the mother reports the infant is breastfeeding well with 4 wet diapers and 1 stool per day. The nurse informs the provider of the assessment and requests which order first?

Question

The 5-day-old 38-week-gestation neonate was born to a 25-year-old primigravida woman after a pregnancy and vacuum-assisted delivery complicated by gestational diabetes, large for gestational age fetus, and shoulder dystocia. The neonate required vigorous stimulation and positive pressure ventilation. Apgar scores were 3 and 8 at 1 and 5 minutes of life. At the pediatrician&rsquo;s appointment after discharge, the neonate is found to have a large bruise at the back of the head that was sustained during birth and eyes glued shut with yellow, mucopurulent discharge. A gram stain of the drainage reveals gram-negative cocci in pairs. The mother states, &ldquo;No matter what I do, it keeps coming back. I&rsquo;ve used warm compresses and washed it away.&rdquo; Additionally, the mother reports the infant is breastfeeding well with 4 wet diapers and 1 stool per day. The nurse informs the provider of the assessment and requests which order first?

Accepted Answer

Total and direct bilirubin. The child likely has gonococcal conjunctivitis that was contracted during the vaginal delivery. It is treated with one intramuscular injection of ceftriaxone. However, the neonate&rsquo;s bilirubin level must be checked before treatment because ceftriaxone increases bilirubin level by displacing the bilirubin attached to albumin. The neonate sustained bruising during birth and although the mother states the baby is breastfeeding well, the baby only has 4 wet diapers and 1 stool per day, which is less than normal for a breastfed baby. It is possible the baby is not eating much. The bruising and poor breastfeeding place the patient at risk for hyperbilirubinemia, so this must be checked prior to administering the medication to prevent encephalopathy. Topical erythromycin is used prophylactically at birth to prevent neonatal conjunctivitis; it is not used to treat the condition. A complete blood count is not necessary given the history.

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