ATI Ob Chapter 27 Assessment and Management of Newborn Complications

late preterm newborn's birth

occurs from 34 to 36 weeks of gestation

early term newborn's birth

occurs from 37 to 38 6⁄7 weeks of gestation.

Neonatal substance withdrawal: Risk Factors

● Maternal use of substances prior to knowing she is pregnant ● Maternal substance use during pregnancy

Hypoglycemia Risk Factors

●Maternal DM ●Preterm infant ●LGA or SGA ●Stress at birth, such as cold stress and asphyxia

Hypoglycemia: Nursing Care

●Obtain blood by heel stick for glucose monitoring. ●An asymptomatic at-risk newborn who has a blood glucose level 25 mg/dL in the first 4 hr, or less than 35 mg/dL from 4 hr to 24 hr of age, should be offered oral feedings to increase levels to greater than 45 mg/dL. ●Initiate IV dextrose for a symptomatic newborn. ●Provide frequent oral and/or gavage feedings or continuous parenteral nutrition early after birth to treat hypoglycemia. ●Monitor the neonate's blood glucose level closely per facility protocol. ●Monitor IV if the neonate is unable to feed orally. ●Maintain skin-to-skin contact to treat hypothermia.

Hypoglycemia Expected findings/Physical Assessment findings

●Poor feeding ●Jitteriness/tremors ●Hypothermia ●Diaphoresis ●Weak cry ●Lethargy ●Flaccid muscle tone ●Seizures/coma ●Irregular respirations ●Cyanosis ●Apnea

Small for gestational age newborn (SGA)

●SGA describes a newborn whose birth weight is at or below the 10th percentile and who has intrauterine growth restriction.

PreTerm Newborn: Nursing Care

●Perform rapid initial assessment. ●Perform resuscitative measures if needed. ●Monitor the newborn's vital signs. ●Assess the newborn's ability to consume and digest nutrients. Before feeding by breast or nipple, the newborn must have an intact gag reflex and be able to suck and swallow to prevent aspiration. ●Monitor I&O and daily weight. ●Monitor the newborn for bleeding from puncture sites and the gastrointestinal tract ●Ensure and maintain thermoregulation in a newborn who is preterm by using a radiant heat warmer ◯Manifestations of hypothermia: Apnea, cyanosis, hypoglycemia, feeding intolerance, lethargy, irritability, bradycardia. ●Administer respiratory support measures, such as surfactant and/or oxygen administration. ●Administer parental or enteral nutrition and fluids as prescribed (most preterm newborns who are less than 34 weeks of gestation will receive fluids either by IV and/or gavage feedings). Provide for nonnutritive sucking, such as using a pacifier while gavage feeding. ●Minimize the newborn's stimulation. Cluster nursing care. Touch the newborn very smoothly and lightly. Keep lighting dim and noise levels reduced. ●Position the newborn in neutral flexion with his extremities close to his body to conserve body heat. Prone and side-lying positions are preferred to supine with body containment using blanket rolls and swaddling, but only in the nursery under monitored supervision. ●Perform a skin assessment tool daily to minimize risk of skin breakdown. ●Encourage skin to skin contact (Kangaroo care) whenever possible to reduce preterm infant stress. Protect the newborn against infection by enforcing hand hygiene and gowning procedures. ◯Equipment should not be shared with other newborns. ◯Evidence of infection: Temperature instability, lethargy, irritability, cyanosis, bradycardia or tachycardia, apnea or tachypnea, feeding intolerance, glucose instability

Congenital anomalies: Diagnostic and Therapeutic Procedures

●Prenatal screening for congenital anomalies can be done by ultrasound and multiple-marker screening (triple and quad screen). ●Confirmation of a diagnosis depends on the anomaly. ●Prenatal diagnosis or confirmation of congenital anomalies is often made by amniocentesis, chorionic villi sampling, or ultrasound. ●Routine testing of newborns for metabolic disorders (inborn errors of metabolism) ◯A Guthrie test for PKU is done to show elevations of phenylalanine in the blood and urine. It is not reliable until the newborn has ingested sufficient amounts of protein. ◯Monitor blood and urine levels of galactose (galactosemia). ◯Measure thyroxine (hypothyroidism). ◯Cytologic studies (karyotyping of chromosomes), such as a buccal smear, uses cells scraped from the mucosa from inside the newborn's mouth

LGA: Nursing Care Prior to delivery

●Prepare the client for a possible vacuum-assisted or cesarean birth. ●Prepare to place the client in McRoberts position (lithotomy position with legs flexed to chest to maximize pelvic outlet). ●Prepare to apply suprapubic pressure to aid in thedelivery of the anterior shoulder, which is located inferior to the maternal symphysis pubis. ●Assess the newborn for birth trauma, such as a broken clavicle or Erb-Duchenne paralysis.

Respiratory distress syndrome, asphyxia, and meconium aspiration: Risk Factors

●Preterm gestation ●Perinatal asphyxia (meconium staining, cord prolapse, nuchal cord) ●Maternal diabetes mellitus ●Premature rupture of membranes ●Maternal use of barbiturates or narcotics close to birth ●Maternal hypotension ●Cesarean birth without labor ●Hydrops fetalis (massive edema of the fetus caused by hyperbilirubinemia) ●Maternal bleeding during the third trimester ●Hypovolemia ●Genetics: male gender, Caucasian descent

Congenital anomalies: Nursing Care of Neurologic anomalies (spina bifida)

●Protect the membrane with a sterile covering and plastic to prevent drying. ●Observe for leakage of cerebrospinal fluid. ●Handle the newborn gently by positioning him prone to prevent trauma. ●Prevent infection by keeping the area free from contamination by urine and feces. ●Measure the circumference of the newborn's head to identify hydrocephalus. ●Assess the newborn for increased intracranial pressure.

Newborn infection, sepsis (sepsis neonatorum): Pt Education: Discharge Instructions

●Provide the family with education about infection control. ◯Instruct them how to use clean bottles and nipples for each feeding. ◯Discard any unused formula. ◯Supervise hand hygiene ●Promote adequate rest for newborn, and decrease physical stimulation. ●Provide emotional support to the family.

Respiratory distress syndrome, asphyxia, and meconium aspiration

●RDS occurs as a result of surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure. ●Surfactant is a phospholipid that assists in alveoli expansion. Surfactant keeps alveoli from collapsing and allows gas exchange to occur. ●Atelectasis (collapsing of a portion of lung) increases the work of breathing. As a result, respiratory acidosis and hypoxemia can develop. ●Birth weight alone is not an indicator of fetal lung maturity.

Neonatal substance withdrawal: Pt education

●Refer the mother to a drug and/or alcohol treatment center. ●Discuss the importance of SIDS prevention activities due to the increased rate in newborns of mothers who used methadone.

TYPES OF BIRTH INJURIES

●Skull: Linear fracture, depressed fracture ●Scalp: Caput succedaneum, hemorrhage ●Intracranial: Epidural or subdural hematoma, contusions ●Spinal cord: Spinal cord transaction or injury, vertebral artery injury ●Plexus: Brachial plexus injury, Klumpke's palsy ●Cranial and peripheral nerve: Radial nerve palsy, diaphragmatic paralysis

Respiratory distress syndrome, asphyxia, and meconium aspiration: Nursing care

●Suction the newborn's mouth, trachea, and nose as needed. ●Maintain thermoregulation. ●Provide mouth and skin care. ●Correct respiratory acidosis with ventilatory support. ●Correct metabolic acidosis by administering sodium bicarbonate. ●Maintain adequate oxygenation, prevent lactic acidosis, and avoid the toxic effects of oxygen. ●Monitor pulse oximetry. ●Provide parenteral nutrition as prescribed. ●Monitor laboratory results, I&O, and weight to evaluate hydration status. ●Decrease stimuli.

Respiratory distress syndrome, asphyxia, and meconium aspiration: Expected findings/physical assessment findings

●Tachypnea (respiratory rate greater than 60/min) ●Nasal flaring ●Expiratory grunting ●Retractions ●Labored breathing with prolonged expiration ●Fine crackles on auscultation ●Cyanosis ●Unresponsiveness, flaccidity, and apnea with decreased breath sounds (manifestations of worsened RDS)

Newborn infection, sepsis (sepsis neonatorum): Expected Findings/Physical Assessment

●Temperature instability ●Suspicious drainage (eyes, umbilical stump) ●Poor feeding pattern, such as weak suck or decreased intake ●Vomiting and diarrhea ●Hypoglycemia, hyperglycemia ●Abdominal distention ●Apnea, retractions, grunting, nasal flaring ●Decreased oxygen saturation ●Color changes, such as pallor, jaundice, and petechiae ●Tachycardia or bradycardia ●Tachypnea ●Low blood pressure ●Irritability and seizure activity ●Poor muscle tone and lethargy

Postmature Newborn: Expected findings/Physical Assessment

●Wasted appearance, thin with loose skin, having lost some of the subcutaneous fat ●Peeling, cracked, and dry skin; leathery from decreased protection of vernix and amniotic fluid ●Long, thin body ●Meconium staining of fingernails and umbilical cord ●Hair and nails can be long ●Alertness similar to a 2-week-old newborn ●Difficulty establishing respirations secondary to meconium aspiration ●Hypoglycemia due to insufficient stores of glycogen ●Clinical findings of cold stress ●Neurological manifestations that become apparent with the development of fine motor skills ●Macrosomia

LGA Expected Findings/Physical Assessment Findings

●Weight above 90th percentile (4,000 g) ●Large head ●Plump and full-faced (cushingoid appearance) from increased subcutaneous fat ●Manifestations of hypoxia including tachypnea,retractions, cyanosis, nasal flaring, and grunting ●Birth trauma (e.g., fractures, shoulder dystocia, intracranial hemorrhage, and CNS injury) ●Sluggishness, hypotonic muscles, and hypoactivity ●Tremors from hypocalcemia ●Hypoglycemia ●Respiratory distress from immature lungs or meconium aspiration

SGA: Expected findings/Physical Assessment findings

●Weight below 10th percentile ●Normal skull, but reduced body dimensions ●Hair is sparse on scalp ●Wide skull sutures from inadequate bone growth ●Dry, loose skin ●Decreased subcutaneous fat ●Decreased muscle mass, particularly over the cheeks and buttocks ●Thin, dry, yellow, and dull umbilical cord rather than gray, glistening, and moist ●Drawn abdomen rather than well-rounded ●Respiratory distress and hypoxia ●Wide-eyed and alert, which is attributed to prolonged fetal hypoxia ●Hypotonia ●Evidence of meconium aspiration ●Hypoglycemia ●Acrocyanosis

Hyperbilirubinemia: Expected findings/Physical Assessment Findings

●Yellowish tint to skin, sclera, and mucous membranes. ●To verify jaundice, press the newborn's skin on the cheek or abdomen lightly with one finger. Then, release pressure, and observe the newborn's skin color for yellowish tint as the skin is blanched. ●Note the time of jaundice onset. ●Assess the underlying cause by reviewing the maternal prenatal, family, and newborn history. ●Hypoxia, hypothermia, hypoglycemia, and metabolic acidosis can occur as a result of hyperbilirubinemia and can increase the risk of brain damage.

Postmature Newborn: Risk Factors

In most cases, the cause of a pregnancy that extends beyond 40 weeks of gestation is unknown, but there is a higher incidence in first pregnancies and in women who have had a previous postmature pregnancy.

Factors that can accelerate lung maturation in the fetus while in utero

Include increased gestational age, intrauterine stress, exogenous steroid use, and ruptured membranes

Methadone Withdrawl: Expected findings

Manifestations of neonatal abstinence syndrome: Increased incidence of seizures, sleep pattern disturbances, higher birth weights (compared to with heroin exposure)

What is the leading risk factor for LGA?

Uncontrolled hyperglycemia during pregnancy

What can untreated hypoglycemia lead to?

Untreated hypoglycemia can result in seizures, brain damage, or death.

Acute bilirubin encephalopathy

When the bilirubin is deposited in the brain. This occurs once all of the binding sites for the bilirubin are used within the body, resulting in necrosis of neurons. Bilirubin levels higher than 25 mg/dL that place the newborn at risk. This can result in permanent damage including dystonia and athetosis, upward gaze, hearing loss, and cognitive impairments

Congenital anomalies: Nutrition for Tracheoesophageal atresia:

Withhold feedings until esophageal patency is determined. Elevate the head of the newborn's crib to prevent gastric juice reflux. Supervise the first feeding to observe for this anomaly.

What do postmature newborns have a risk of?

increased risk for aspirating the meconium passed by the fetus in utero.

Common complications of newborns who are SGA

perinatal asphyxia, meconium aspiration, hypoglycemia, polycythemia, and instability of body temperature

Marijuana Withdrawl: Expected findings

● Preterm birth, meconium staining ● Long‑term effects, such as deficits in attention, cognition, memory, and motor skills

Congenital anomalies: Nursing Assessment

●Newborn's ability to take in adequate nourishment ●Newborn's ability to eliminate waste products ●Vital signs and axillary temperature ●Newborn-parental bonding, observing the parent's response to the diagnosis of a congenital defect, and encouraging the parents to verbalize concerns

Large for gestational age (macrosomic) newborn (LGA)

●Occurs in neonates who weigh above the 90th percentile or more than 4,000 g (8 lb, 13 oz). ●Neonates who are LGA can be preterm, postmature, or full-term

Newborn infection, sepsis (sepsis neonatorum): Risk Factors

●Premature rupture of membranes ●Prolonged labor ●Toxoplasmosis, rubella, cytomegalovirus, and herpes (TORCH) ●Chorioamnionitis ●Preterm birth ●Low birth weight ●Maternal substance use ●Maternal urinary tract infection ●Meconium aspiration ●HIV transmitted from the mother to the newborn perinatally through the placenta and postnatally through the breast milk

SGA: Nursing Care

●Support respiratory efforts, and suction the newborn as necessary to maintain an open airway. ●Provide a neutral thermal environment for the newborn (isolette or radiant heat warmer) to prevent cold stress. ●Initiate early feedings. (A newborn who is SGA will require feedings that are more frequent.) ●Administer parenteral nutrition if necessary. ●Maintain adequate hydration. ●Conserve the newborn's energy level. ●Prevent skin breakdown. ●Protect the newborn from infection.

Dysmaturity from placental degeneration and uteroplacental insufficiency

(placenta functions effectively for approximately 40 weeks) results in chronic fetal hypoxia and fetal distress in utero. The fetal response is polycythemia, meconium aspiration, and/or neonatal respiratory problems. Perinatal mortality is higher when a postmature placenta fails to meet increased oxygen demands of the fetus during labor

What are macrosomic newborns at risk for?

At risk for birth injuries (shoulder dystocia, clavicle fracture or a cesarean birth, asphyxia, hypoglycemia, polycythemia and Erb-Duchenne paralysis due to birth trauma).

Neonatal substance withdrawal: Medications

Based on withdrawal symptoms. Morphine sulfate CLASSIFICATION: Opioid Phenobarbital CLASSIFICATION: Anticonvulsant INTENDED EFFECT: Decrease CNS irritability and control seizures for newborns who have alcohol or opioid withdrawal.

Respiratory distress syndrome, asphyxia, and meconium aspiration: Medications

Beractant, calfactant, lucinactant CLASSIFICATION: Lung surfactant INTENDED EFFECT: Restores surfactant and improves respiratory compliance for newborns who are premature and have RDS NURSING CONSIDERATIONS ●Perform a respiratory assessment including ABGs, respiratory rhythm, and rate and skin color before and after administration of agent. ●Provide suction to the newborn prior to administration of the medication. ●Assess endotracheal tube placement. ●Avoid suctioning of the endotracheal tube for 1 hr after administration of the medication.

Birth trauma or injury: Diagnostic Procedures

Birth injuries are normally diagnosed by a CT scan, x-ray of suspected area of fracture, or neurological exam to determine paralysis of nerves.

Birth trauma or injury

Birth injury occurs during childbirth resulting in physical injury to a newborn. Most injuries are minor and resolve rapidly. Other injuries can require some intervention. A few are serious enough to be fatal

Hypoglycemia: Lab tests

Blood glucose levels less than 45 mg/dL should be followed up with a serum glucose level.

Neonatal substance withdrawal: Lab tests

Blood tests should be done to differentiate between neonatal drug withdrawal and CNS disorders. ● CBC ● Blood glucose ● Electrolyte imbalance ● Thyroid‑stimulating hormone, thyroxine, triiodothyronine ● Drug screen of urine or meconium to reveal the substance used by the mother ● Hair analysis

Main priority in treating preterm newborns?

◯The main priority in treating newborns who are preterm is supporting the cardiac and respiratory systems as needed. Most newborns who are preterm are cared for in a neonatal intensive care unit (NICU). Meticulous care and observation in the NICU is necessary until the newborn can receive oral feedings, maintain body temperature, and weighs approximately 2 kg (4.4 lb).

Respiratory distress syndrome, asphyxia, and meconium aspiration: Diagnostic Procedures

Chest x-ray

SGA: Diagnostic procedure

Chest x-ray to rule out meconium aspiration syndrom

LGA: Diagnostic Tests

Chest x-ray to rule out meconium aspiration syndrome

Diagnostic test for Fetal Alcohol Syndrome

Chest x‑ray for FAS to rule out congenital heart defects

Congenital anomalies: Expected Fingings

Cleft lip/palate: Opening in the lip or palate Tracheoesophageal atresia: Excessive mucous secretions and drooling, periodic cyanotic episodes and choking, abdominal distention after birth, immediate regurgitation after birth Duodenal atresia: Abdominal distention, bilious vomiting, failure to pass meconium in the first 24 hr PKU: Can result in cognitive impairment if untreated; not evident at birth, but will be identified with neonatal screening Galactosemia: Can result in failure to thrive, cataracts, jaundice, cirrhosis of the liver, sepsis, and cognitive impairment if untreated; this will not be evident at birth, but will be identified with neonatal screening Hypothyroidism: Can result in hypothermia, poor feeding, lethargy, jaundice, and cretinism if untreated Neurologic anomalies (spina bifida): Protrusion of the meninges and/or spinal cord Hydrocephalus: Enlarged head and bulging fontanels; sun-setting sign is common in which the whites of the eyes are visible above the iris Patent ductus arteriosus: Murmurs, abnormal heart rate or rhythm, breathlessness, and fatigue while feeding Tetralogy of Fallot: Respiratory difficulties, cyanosis, tachycardia, tachypnea, and diaphoresis Down syndrome: Oblique palpebral fissures or upward slant of eyes, epicanthal folds, flat facial profile with a depressed nasal bridge and a small nose, protruding tongue, small low-set ears, short broad hands with a fifth finger that has one flexion crease instead of two, a deep crease across the center of the palm (frequently referred to as a simian crease), hyperflexibility, hypotonic muscles

Complications from RDS

Complications from RDS are related to oxygen therapy and mechanical ventilation. ◯Pneumothorax ◯Pneumomediastinum ◯Retinopathy of prematurity ◯Bronchopulmonary dysplasia ◯Infection ◯Intraventricular hemorrhage

Congenital anomalies Types

Congenital anomalies are generally identified soon after birth by Apgar scoring and a brief assessment indicating the need for further investigation. Once identified, congenital anomalies are treated in a pediatric setting. ●Cleft lip/palate: Failure of the lip or hard or soft palate to fuse ●Tracheoesophageal atresia: Failure of the esophagus to connect to the stomach ●Duodenal atresia: Common in newborns who have Down syndrome; when the first part of the small bowel has not developed properly and is not open, and stomach contents are unable to pass. Surgical intervention is required. ●Phenylketonuria (PKU): Inability to metabolize the amino acid phenylalanine ●Galactosemia: Inability to metabolize galactose into glucose ●Hypothyroidism: Slow metabolism caused by maternal iodine deficiency or maternal antithyroid medications during pregnancy ●Neurologic anomalies (spina bifida): A neural tube defect in which the vertebral arch fails to close ●Hydrocephalus: Excessive spinal fluid accumulation in the ventricles of the brain ●Patent ductus arteriosus: A noncyanotic heart defect in which the ductus arteriosus connecting the pulmonary artery and the aorta fails to close after birth ●Tetralogy of Fallot: Cyanotic heart defect characterized by a ventricular septal defect, the aorta positioned over the ventricular septal defect, stenosis of the pulmonary valve, and hypertrophy of the right ventricle ●Down syndrome: Trisomy 21, which is the most common trisomic abnormality with 47 chromosomes in each cell

Physiologic jaundice

Considered benign (resulting from normal newborn physiology of increased bilirubin production due to the shortened lifespan and breakdown of fetal RBCs and liver immaturity). The newborn who has physiological jaundice exhibits an increase in unconjugated bilirubin levels 72 to 120 hr after birth, with a rapid decline to 3 mg/dL 5 to 10 days after birth.

Hyperbilirubinemia: Pt Education

DISCHARGE INSTRUCTIONS ●Educate the parents regarding the newborn's plan of care. ●Advise parents that infants who have low to moderate risk of hyperbilirubinemia should receive follow up care within two days. Infants at higher risk should be seen within 24 hr.

Congenital anomalies: Nutrition for Cleft lip/palate:

Determine the most effective nipple for feeding. Can use specialized bottles, cups, or syringes to feed the infant. Infants who have cleft lip can achieve breastfeeding with changes in positioning. Feed the newborn in the upright position to decrease aspiration risk. Feed the newborn slowly, and burp him frequently so that he does not swallow air. Cleanse his mouth with water after feedings.

Congenital anomalies: Nursing Care of Patent ductus arteriosus

Educate the parents about surgical treatment.

Hyperbilirubinemia

Elevation of serum bilirubin levels resulting in jaundice. Jaundice normally appears on the head (especially the sclera and mucous membranes), and then progresses down the thorax, abdomen, and extremities.

Congenital anomalies: RIsk Factors

GENETIC AND/OR ENVIRONMENTAL FACTORS ●Maternal age greater than 40 years ●Chromosome abnormalities, such as Down syndrome ●Viral infections, such as rubella ●Excessive body heat exposure during the first trimester (neural tube defects) ●Medications and substance use during pregnancy ●Maternal obesity ●Radiation exposure ●Maternal metabolic disorders (phenylketonuria, diabetes mellitus) ●Poor maternal nutrition such as folic acid deficiency (neural tube defects) ●Newborns who are preterm ●Newborns who are SGA ●Oligohydramnios or polyhydramnios

Congenital anomalies: Nutrition for Galactosemia

Give the newborn a soy-based formula because galactose is present in milk. Eliminate lactose and galactose in the newborn's diet. Breastfeeding is also contraindicated.

Kernicterus

Irreversible, chronic result of bilirubin toxicity. The newborn demonstrates many of the same manifestations of bilirubin encephalopathy with hypotonia, severe cognitive impairments, and spastic quadriplegia

Alcohol Withdrawal: Expected findings

Jitteriness, irritability, increased tone and reflex responses, and seizures

When congenital anomalies are present at birth, they can involve any of the body systems

Major anomalies causing serious problems include the following. ●Congenital heart disease:Atrial septal defects, ventricular septal defects, coarctation of the aorta, tetralogy of Fallot, transposition of the great vessels, stenosis, atresia of valves ●Neurological defects: Neural tube defects, hydrocephalus, anencephaly, encephalocele, meningocele, myelomeningocele ●Gastrointestinal problems: Cleft lip/palate, diaphragmatic hernia, imperforate anus, tracheoesophageal fistula/ esophageal atresia, duodenal atresia, omphalocele, gastroschisis, umbilical hernia, intestinal obstruction ●Musculoskeletal deformities: Clubfoot, polydactyly, developmental dysplasia of the hip ●Genitourinary deformities: Hypospadias, epispadias, exstrophy of the bladder ●Metabolic disorders: Phenylketonuria, galactosemia, hypothyroidism ●Chromosomal abnormalities

Neonatal substance withdrawal: Expected Findings

Monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and scores the following. ● CNS: High‑pitched, shrill cry; incessant crying; irritability; tremors; hyperactivity with an increased Moro reflex; increased deep‑tendon reflexes; increased muscle tone; disturbed sleep pattern; hypertonicity; convulsions ● Metabolic, vasomotor, and respiratory findings: Nasal congestion with flaring, frequent yawning, skin mottling, retractions, apnea, tachypnea greater than 60/min, sweating, temperature greater than 37.2° C (99° F) ● Gastrointestinal: Poor feeding; regurgitation (projectile vomiting); diarrhea; excessive, uncoordinated, constant sucking

Congenital anomalies

Newborns can be born with congenital anomalies involving all systems. Anomalies are often diagnosed prenatally. A nurse should provide emotional support to the parents whose newborn is facing procedures or surgeries to correct the defects.

Neonatal substance withdrawal: Nursing Care

Nursing care for maternal substance use and neonatal effects or withdrawal include the following in addition to normal newborn care. ● Perform ongoing assessment of the newborn using the neonatal abstinence scoring system assessment, as RX'ed. ● Elicit and assess the newborn's reflexes. ● Monitor the newborn's ability to feed and digest intake. Offer small frequent feedings. ● Swaddle the newborn with legs flexed. ● Offer non‑nutritive sucking. ● Monitor the newborn's fluids and electrolytes with skin turgor, mucous membranes, fontanels, daily weights, and I&O. ● Reduce environmental stimuli (decrease lights, lower noise level).

Congenital anomalies: Nursing Care

Nursing interventions for congenital anomalies are dependent upon the type and extent of the anomaly. ●Establish and maintain adequate respiratory status. ●Establish and maintain extrauterine circulation. ●Establish and maintain adequate thermoregulation. ●Administer medications as prescribed, such as thyroid replacement for hypothyroidism. ●Educate the parents regarding preoperative and postoperative treatment procedures. ●Encourage the parents to hold, touch, and talk to the newborn. ●Ensure that parents provide consistent care to the newborn. ●Provide parents with information about parent groups or support systems.

What is complication that can result from meconium aspiration>

Persistent pulmonary hypertension (persistent fetal circulation) There is an interference in the transition from fetal to neonatal circulation, and the ductus arteriosus (connecting the main pulmonary artery and the aorta) and foramen ovale (shunt between the right and left atria) remain open, and fetal pathways of blood flow continue

Tobacco use: Expected findings

Prematurity, low birth weight, increased risk for SIDS, increased risk for bronchitis, pneumonia, and developmental delays

Newborn sepsis

Prescence of micro-organisms or their toxins in the blood or tissues of the newborn during the first month after birth. Manifestations of sepsis are subtle and can resemble other diseases; the nurse often notices them during routine care of the newborn.

Amphetamine Withdrawl: Expected findings

Preterm or SGA, drowsiness, jitteriness, sleep pattern disturbances, respiratory distress, frequent infections, poor weight gain, emotional disturbances, and delayed growth and development

Preterm Newborn Complications:

Respiratory distress syndrome:Decreased surfactant in the alveoli occurs, regardless of a newborn's birth weight Bronchopulmonary dysplasia: Causes the lungs to become stiff and noncompliant, requiring a newborn to receive mechanical ventilation and oxygen. It is sometimes difficult to remove the newborn from ventilation and oxygen after initial placement. Aspiration: A result of a newborn who is premature not having an intact gag reflex or the ability to effectively suck or swallow Apnea of prematurity: A result of immature neurological and chemical mechanisms Intraventricular hemorrhage: Bleeding in or around the ventricles of the brain Retinopathy of prematurity: Disease caused by abnormal growth of retinal blood vessels and is a complication associated with oxygen administration to the newborn; can cause mild to severe eye and vision problems Patent ductus arteriosus: Occurs when the ductus arteriosus reopens after birth due to neonatal hypoxia Necrotizing enterocolitis: An inflammatory disease of the gastrointestinal mucosa due to ischemia. It results in necrosis and perforation of the bowel. (Short-gut syndrome can be the result secondary to removal of most or part of the small intestine due to necrosis.) Additional complications: Infection, hyperbilirubinemia, anemia, hypoglycemia, and delayed growth and development

Pathologic jaundice

Result of an underlying disease. Pathologic jaundice appears before 24 hr of age or is persistent after day 14. In the term newborn, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 12.9 mg/dL, or is associated with anemia and hepatosplenomegaly. Pathologic jaundice is usually caused by a blood group incompatibility or an infection, but can be the result of RBC disorders

Fetal alcohol syndrome (FAS)

Results from the chronic or periodic intake of alcohol during pregnancy. Alcohol is considered teratogenic, so the daily intake of alcohol increases the risk of FAS. Newborns who have FAS are at risk for specific congenital physical defects and long‑term complications.

Birth trauma or injury: Nursing Care

Review maternal history for factors that can predispose the newborn to injuries. ●Review Apgar scoring that might indicate a possibility of birth injury. ●Perform frequent head-to-toe physical assessments. ●Obtain vital signs and temperature. ●Promote parent-newborn interaction as much as possible. ●Administer treatment to the newborn based on the injury and according to the provider's prescriptions

Congenital anomalies: Nutrition for PKU

Specialized synthetic formula in which phenylalanine is removed or reduced. The mother should restrict meat, dairy products, diet drinks (artificial sweeteners), and protein during pregnancy. Aspartame must be avoided.

Organisms frequently responsible for newborn infections

Staphylococcus aureus Staphylococcus epidermidis Escherichia coli Haemophilus influenzae streptococcus ß-hemolytic, Group B

Which medications would mother use for neonatal substance withdrawal occur?

Substance withdrawal in the newborn occurs when the mother uses drugs that have addictive properties during pregnancy. This includes illegal drugs, alcohol, tobacco, and prescription medications.

Hyperbilirubinemia: Phototherapy

The newborn's bilirubin should start to decrease within 4 to 6 hr after starting treatment. ●Set up phototherapy if prescribed. ◯Maintain an eye mask over the newborn's eyes for protection of corneas and retinas. ◯Keep the newborn undressed. For a male newborn, a surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. ◯Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. ◯Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. ◯Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ◯Check the lamp energy with a photometer per facility protocol. ◯Turn off the phototherapy lights before drawing blood for testing. ●Observe the newborn for effects of phototherapy. ◯Bronze discoloration: not a serious complication ◯Maculopapular skin rash: not a serious complication ◯Development of pressure areas ◯Dehydration: poor skin turgor, dry mucous membranes, decreased urinary output ◯Elevated temperature ●Encourage the parents to hold and interact with the newborn when phototherapy lights are off.

Hypoglycemia

The newborn's source of glucose stops when the umbilical cord is clamped. A healthy term newborn's blood glucose level can drop to 30 mg/dL the first 1 to 2 hr following birth. If newborns have other physiological stress, they can experience hypoglycemia due to inadequate gluconeogenesis or increased use of glycogen stores. ● Hypoglycemia is a serum glucose level less than 40 mg/dL. Routine assessment of all newborns, especially newborns who are LGA and SGA, should include monitoring for hypoglycemia. ●Hypoglycemia differs for a newborn who is preterm or term. Hypoglycemia in the first 3 days of life in the term newborn is defined as a blood glucose level less than 40 mg/dL.

Hyperbilirubinemia: Diagnostic Procedure

Transcutaneous bilirubin level is a noninvasive method to measure a newborn's bilirubin level

Continued growth of the fetus in utero

because the placenta continues to function effectively and the newborn becomes LGA at birth. This leads to a difficult delivery, cephalopelvic disproportion, as well as high insulin reserves and insufficient glucose reserves at birth. The neonatal response can be birth trauma, perinatal asphyxia, a clavicle fracture, seizures, hypoglycemia, and/or temperature instability (cold stress).

What can Uncontrolled hyperglycemia during pregnancy lead to?

can lead to congenital defects with the most common being congenital heart defects, tracheoesophageal fistula, and CNS anomalies.

Findings of increased intracranial pressure:

dilated pupils, vomiting, bulging fontanels, high-pitched cry

Preterm Newborn: Findings of overhydration (resulting from IV nutrition and fluid administration)

■Urine output greater than 3 mL/kg/hr ■Urine-specific gravity less than 1.001 ■Edema ■Increased weight gain ■Crackles in lungs ■Intake greater than output

Preterm Newborn: Findings of dehydration (resulting from IV nutrition and fluid administration)

■Urine output less than 1 mL/kg/hr ■Urine-specific gravity greater than 1.015 ■Weight loss ■Dry mucous membranes ■Absent skin turgor ■Depressed fontanel

Fetal Alcohol Syndrome: Expected findings

● Facial anomalies: small eyes, flat midface, smooth philtrum, thin upper lip, eyes with a wide spaced appearance, epicanthal folds, strabismus, ptosis, poor suck, small teeth, and cleft lip or palate ● Deafness ● Abnormal palmar creases and irregular hair ● Many vital organ anomalies, such as heart defects, including atrial and ventricular septal defects, tetralogy of Fallot, and patent ductus arteriosus ● Developmental delays and neurologic abnormalities ● Prenatal and postnatal growth delays ● Sleep disturbances

Neonatal substance withdrawal: Long term Complications

● Feeding problems ● CNS dysfunction (cognitive impairment, cerebral palsy) ● Attention deficit disorder ● Language abnormalities ● Microcephaly ● Delayed growth and development ● Poor maternal‑newborn bonding

Heroin Withdrawl: Expected findings

● Low birth weight ● Small for gestational age (SGA) ● Manifestations of neonatal abstinence syndrome ● Increased risk of sudden infant death syndrome (SIDS)

Postmature infant

●A newborn who is postmature is born after the completion of 42 weeks of gestation. ●A newborn who is postmature can be either SGA or LGA depending on how well the placenta functions during the last weeks of pregnancy. Postmaturity of the infant can be associated with either of the following. ◯Dysmaturity from placental degeneration and uteroplacental insufficiency ◯Continued growth of the fetus in utero

Preterm newborn

●A preterm newborn's birth occurs after 20 weeks of gestation and before completion of 37 weeks of gestation Preterm newborns are at risk for a variety of complications due to immature organ systems. The degree of complications depends on gestational age. There is a decreased risk for complications the closer the newborn is to 40 weeks of gestation. ◯Goals include meeting the newborn's growth and development needs, and anticipating and managing associated complications such as RDS and sepsis.

Respiratory distress syndrome, asphyxia, and meconium aspiration: Lab tests

●ABGs ●CBC with differential ●Culture and sensitivity of the blood, urine, and cerebrospinal fluid ●Blood glucose

Hyperbilirubinemia: Lab Tests

●An elevated serum bilirubin level can occur (direct and indirect bilirubin). Monitor the newborn's bilirubin levels every 4 hr until the level returns to normal. ●Assess maternal and newborn blood type to determine whether there is ABO incompatibility. This occurs if the newborn has blood type A or B, and the mother is type O. ●Review Hgb and Hct. ●A direct Coombs' test reveals the presence of antibody-coated (sensitized) Rh-positive RBCs in the newborn. ●Check electrolyte levels for dehydration from phototherapy

Neonatal substance withdrawal: Medications Nursing Considerations

●Assess IV site frequently (phenobarbital). ●Check for any medication incompatibilities. ●Decrease environmental stimuli. ●Cluster cares to minimize stimulation. ●Swaddle the newborn to reduce self-stimulation and protect the skin from abrasions. ●Monitor and maintain fluids and electrolytes. ●Administer frequent, small feedings of high-calorie formula; can require gavage feedings. ●Elevate the newborn's head during and following feedings, and burp the newborn to reduce vomiting and aspiration. ●Try various nipples to compensate for a poor suck reflex. ●Have suction available to reduce the risk for aspiration. ●For newborns who are withdrawing from cocaine, avoid eye contact and use vertical rocking and a pacifier. ●Prevent infection. ●Initiate a consult with child protective services. ●Consult lactation services to evaluate whether breastfeeding is desired or contraindicated to avoid passing narcotics in breast milk. Methadone is not contraindicated during breastfeeding.

Newborn infection, sepsis (sepsis neonatorum): Nursing Care

●Assess infection risks. (Review maternal health record.) ●Monitor for clinical findings of opportunistic infection. ●Monitor vital signs continuously. ●Monitor I&O and daily weight. ●Monitor fluid and electrolyte status. ●Monitor the newborn's visitors for infection. ●Obtain specimens (blood, urine, stool) to assist in identifying the causative organism. ●Initiate and maintain IV therapy as prescribed to administer electrolyte replacements, fluids, and medications ●Isolation precautions as indicated. ●Administer medications as prescribed (antibiotics, antivirals, or antifungals). ●Initiate and maintain respiratory support as needed. ●Assess IV site for evidence of infection. ●Provide newborn care to maintain temperature. ●Clean and sterilize all equipment to be used.

Preterm Newborn: Expected findings/Physical Assessment Findings

●Ballard assessment showing a physical and neurological assessment totaling less than 37 weeks of gestation ●Periodic breathing consisting of 5- to 10-second respiratory pauses, followed by 10- to 15-second compensatory rapid respirations ●Manifestations of increased respiratory effort and/or respiratory distress including nasal flaring or retractions of the chest wall during inspirations, expiratory grunting, and tachypnea ●Apnea: a pause in respirations 20 seconds or greater ●Low birth weight ●Minimal subcutaneous fat deposits ●Head that is large in comparison with his body, and small fontanels ●Wrinkled features with abundance of lanugo covering back, forearms, forehead, and sides of face, and few or no creases on soles of feet ●Skull and rib cage that feel soft ●Eyes closed if the newborn is born at 22 to 24 weeks of gestation ●Weak grasp reflex ●Inability to coordinate suck and swallow; weak or absent gag, suck, and cough reflex; weak swallow ●Hypotonic muscles, decreased level of activity, and a weak cry for more than 24 hr ●Lethargy, tachycardia, and poor weight gain

SGA: Lab Tests

●Blood glucose for hypoglycemia ●CBC will show polycythemia resulting from fetal hypoxia and intrauterine stress. ●ABGs may be prescribed due to chronic hypoxia in utero due to placental insufficiency.

LGA: Lab Tests

●Blood glucose levels to monitor closely for hypoglycemia ●ABGs may be prescribed due to chronic hypoxia in utero secondary to placental insufficiency. ●CBC shows polycythemia (Hct greater than 65%) from in utero hypoxia. ●Hyperbilirubinemia resulting from polycythemia as excessive RBCs break down after birth. ●Hypocalcemia can result in response to a long and difficult birth.

Postmature Newborn: Lab tests

●Blood glucose levels to monitor for hypoglycemia ●ABGs secondary to chronic hypoxia in utero due to placental insufficiency ●CBC can show polycythemia from decreased oxygenation in utero ●Hct elevated from polycythemia and dehydration

Preterm Newborn: Lab Tests

●CBC showing decreased Hgb and Hct as a result of slow production of RBCs ●Urinalysis and specific gravity ●Increased PT and aPTT time with an increased tendency to bleed ●Serum glucose ●Calcium ●Bilirubin ●ABGs

Newborn infection, sepsis (sepsis neonatorum): Lab Tests

●CBC with differential, C-reactive protein ●Blood, urine, and cerebrospinal fluid cultures and sensitivities ●Chemical profile shows a fluid and electrolyte imbalance

Postmature Newborn: Diagnostic Procedures

●Cesarean birth ●Chest x-ray to rule out meconium aspiration syndrome

Preterm Newborn: Diagnostic Procedures

●Chest x-ray ●Head ultrasounds ●Echocardiography ●Eye exams

SGA: Risk Factors

●Congenital or chromosomal anomalies ●Maternal infections, disease, or malnutrition ●Gestational hypertension and/or diabetes ●Maternal smoking, drug, or alcohol use ●Multiple gestations ●Placental factors (small placenta, placenta previa, decreased placental perfusion) ●Fetal congenital infections such as rubella or toxoplasmosis

Congenital anomalies: Nursing Care of Tetralogy of Fallot

●Conserve the newborn's energy to reduce the workload on the heart. ●Administer gavage feedings, or give oral feedings with a specialized nipple. ●Elevate the newborn's head and shoulders to improve respirations and reduce the cardiac workload. ●Prevent infection. ●Place the newborn in a knee-chest position during respiratory distress.

Congenital anomalies: Nursing Care of Cleft lip/palate

●Encourage expression of parental concerns, grief, and fears. ●Monitor the newborn's weight daily while hospitalized. ●Monitor for manifestations of dehydration. ●Encourage parental attachment. ●Suction nose and mouth gently with bulb syringe as needed to clear airway. ●Position infant facilitate drainage of sections. ●Educate parents on feeding requirements of infants

Congenital anomalies: Nursing Care of Hydrocephalus

●Frequently reposition the newborn's head to prevent sores. ●Measure the newborn's head circumference daily. ●Assess for manifestations of increased intracranial pressure, such as vomiting and a shrill cry.

Hyperbilirubinemia: Risk Factors

●Increased RBC production or breakdown ●Rh or ABO incompatibility ●Decreased liver function ●Maternal ingestion of diazepam, salicylates, or sulfonamides close to birth ●Maternal diabetes ●Oxytocin during labor ●Neonatal hyperthyroidism ●Ecchymosis or hemangioma ●Prematurity

Newborn infection, sepsis (sepsis neonatorum)

●Infection can be contracted by the newborn before, during, or after delivery. Newborns are more susceptible to micro-organisms due to their limited immunity and inability to localize infection. The infection can spread rapidly into the bloodstream Prevention of infection and newborn sepsis starts perinatally with maternal screening for infections, prophylactic interventions, and the use of sterile and aseptic techniques during delivery. Prophylactic antibiotic treatment of the eyes of all newborns and appropriate umbilical cord care also help to prevent newborn infection and sepsis.

Birth trauma or injury: Expected findings/Physical Assessment Findings

●Irritability, seizures within the first 72 hr, and decreased level of consciousness are manifestations of a subarachnoid hemorrhage. ●Facial flattening and unresponsiveness to grimace that accompanies crying or stimulation, as well as eyes remaining open, are findings to assess for facial paralysis. ●A weak or hoarse cry is characteristic of laryngeal nerve palsy from excessive traction on the neck. ●Flaccid muscle tone can signal joint dislocations and separation during birth. ●Flaccid muscle tone of the extremities suggests nerve-plexus injuries or long bone fractures. ●Limited motion of an arm, crepitus over a clavicle, and absence of the Moro reflex on the affected side are manifestations of clavicular fractures. ●A flaccid arm with the elbow extended and the hand rotated inward, absence of the Moro reflex on the affected side, sensory loss over the lateral aspect of the arm, and intact grasp reflex are manifestations of Erb-Duchenne paralysis (brachial paralysis). ●Localized discoloration, ecchymosis, petechiae, and edema over the presenting part are seen with soft-tissue injuries.

Birth trauma or injury: Risk Factors

●Maternal age: younger than 16 or older than 35 ●Fetal macrosomia ●Abnormal or difficult presentations ●Prolonged labor ●Precipitous labor ●Oligohydramnios ●Cephalopelvic disproportion ●Multifetal gestation ●Congenital abnormalities ●Internal FHR monitoring ●Forceps or vacuum extraction ●External version ●Cesarean birth

Preterm Newborn: Risk Factors

●Maternal gestational HTN ●Multiple pregnancies that are closely spaced ●Adolescent pregnancy ●Lack of prenatal care ●Maternal substance use, smoking ●Previous history of preterm delivery ●Abnormalities of the uterus ●Cervical incompetence ●Placenta previa ●Preterm labor ●Preterm premature rupture of membranes

Postmature Newborn: Nursing Care

●Monitor vital signs. ●Administer and monitor IV fluids. ●Moisturize the skin with a petrolatum-based ointment ●Use mechanical ventilation if necessary. ●Administer oxygen as prescribed. ●Prepare and/or assist with exchange transfusion if hematocrit is high. ●Provide thermoregulation in an isolette to avoid cold stress. ●Provide early feedings to avoid hypoglycemia. ●Identify and treat any birth injuries

LGA Risk Factors

●Newborns who are postmature ●Maternal diabetes mellitus during pregnancy (high glucose levels stimulate continued insulin production by the fetus) ●Fetal cardiovascular disorder of transposition of the great vessels ●Genetic factors ●Maternal obesity ●A mother who is multiparous

Hyperbilirubinemia:

●Observe the skin and mucous membranes for jaundice. ●Monitor vital signs. ●Monitor elimination and daily weights, watching for evidence of dehydration. ●Check the newborn's axillary temperature every 4 hr during phototherapy because temperature can become elevated. ●Feed the newborn early and frequently, every 3 to 4 hr. This will promote bilirubin excretion in the stools. ●Encourage continued breastfeeding of the newborn. Supplementation with formula may be prescribed. ●Maintain adequate fluid intake to prevent dehydration. ●Reassure the parents that most newborns experience some degree of jaundice. ●Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. ●Explain that the newborn's stool contains some bile that will be loose and green. ●Administer an exchange transfusion for newborns who are at risk for kernicterus.

LGA: Nursing Care For a newborn who is LGA following delivery

●Obtain early and frequent heel sticks (blood glucose testing). ●Initiate early feedings or IV therapy to maintain glucose levels within the expected reference range. ●Provide thermoregulation with an isolette. ●Identify and treat any birth injuries.

Opiate Withdrawl: Expected findings

Manifestations of neonatal abstinence syndrome

Neonatal substance withdrawal

Maternal substance use during pregnancy consists of any use of alcohol or drugs. Intrauterine drug exposure can cause anomalies, neurobehavioral changes, and evidence of withdrawal in the neonate. These changes depend on the specific drug or combination of drugs used, dosage, route of administration, metabolism and excretion by the mother and fetus, timing of drug exposure, and length of drug exposure.

Congenital anomalies: Nutrition for Duodenal atresia

Withhold feedings until surgical repair is done and the newborn has begun to pass stools. Administer IV fluids as prescribed. Monitor for jaundice.