high risk newborn study guide

retinopathy of prematurity

Damage to blood vessels by oxygen use that may cause blindness

Compare early- and late-onset sepsis.

Early-onset sepsis - related to prolonged rupture of membranes, prolonged labor, or chorioamnionitis -it begins within 24 hours of birth and progresses more rapidly - Mortality is 5% to 20% - It often involves the respiratory system or central nervous system Late-onset sepsis -develops after 1 week and is caused by exposure to organisms after birth - It usually involves the central nervous system. - -Mortality is 5%, often with long-term effects.

List four methods to identify intestinal complications.

a. Aspirate for residual from previous feeding. b. Measure abdominal circumference to identify distention. c. Test stool for reducing substance with Clinitest tablet. d. Test for occult blood in stool.

What intervention should be expected for the late preterm infant during the first 24 hours after birth? a. Blood glucose determinations b. Placement under phototherapy c. Surfactant replacement d. Blood transfusions

a. Blood glucose determinations

3. Infants receiving phototherapy should be fed every 2 to 3 hours to: a. promote excretion of bilirubin from the bowel. b. prevent development of hypothermia. c. increase the life span of fetal erythrocytes in the blood. d. increase renal and liver perfusion.

a. promote excretion of bilirubin from the bowel.

3. The purpose of containment in care of the preterm infant is to: a. simulate the enclosed uterine environment when stressful procedures must be performed. b. gradually reduce the percentage of supplemental oxygen needed to prevent hypoxia. c. recover fluid lost by insensible means and return it to the infant. d. limit the formula given by gavage feedings as the infant starts nipple feeding.

a. simulate the enclosed uterine environment when stressful procedures must be performed.

Describe the four major disadvantages the preterm infant has in regulating temperature.

a. thin skin with little insulating fat b. less heat-producing brown fat accumulation c. poor flexion to reduce exposed body surfaces d. immature temperature control center in the brain

1. Naloxone for neonatal use is supplied in 1-mg/ml vials. The correct volume of naloxone for a neonate weighing 5 pounds, 2 ounces is approximately: a. 0.1 ml. b. 0.2 ml. c. 0.3 ml. d. 0.4 ml.

b. 0.2 ml.

The nurse notes that a 12-hour-old infant is jittery, but his blood glucose level is normal. The infant seems hungry but takes only ¼ ounce of formula with difficulty. The nurse's next action should be to: a. recheck the glucose level 30 minutes after the feeding. b. apply a bag to collect the next sample of urine. c. limit infant contact with the mother for the next 12 hours. d. swaddle the infant tightly and try to feed more formula.

b. apply a bag to collect the next sample of urine.

1. To promote drainage of lung secretions in the preterm infant, the nurse should: a. position the infant in a head-down position. b. frequently change the infant's position. c. keep the infant in a supine position with the head elevated. d. place a small roll under the infant's neck and shoulders.

b. frequently change the infant's position.

A mother who has diabetes is concerned because her 36-hour-old baby is "so yellow." She tells the nurse that she thought her baby's problems were over when his blood glucose stabilized even though he was smaller than expected. The best nursing response is that: a. her baby's liver is also less mature than expected and cannot handle normal red blood cell breakdown. b. her baby lived in a lower-than-normal oxygen environment during pregnancy and must eliminate more red blood cells. c. the baby's high blood glucose levels immediately after birth caused a slight dehydration that increases jaundice. d. early feedings slowed elimination of meconium that would have also eliminated excess bilirubin.

b. her baby lived in a lower-than-normal oxygen environment during pregnancy and must eliminate more red blood cells.

5. Nursing care that reduces the risk for periventricular or intraventricular hemorrhage includes: a. assessing for abnormal heart rhythms or murmurs. b. minimal and gentle handling of the infant. c. limiting the duration of parental visits. d. examining the eyes at 4 weeks and 8 weeks.

b. minimal and gentle handling of the infant.

What are the two complications of oxygen therapy that may be manifested in preterm infants?

bronchopulmonary dysplasia retinopathy of prematurity

2. After discharge teaching to the parents of a preterm infant, the nurse evaluates understanding of the information when the parent states: a. "I don't have to worry about feeding my baby at night if he is asleep." b. "The car seat I used for my other children will work with this baby."c. "My baby will probably start walking later than my other children."d. "My baby will take less care than my other children when they were newborns.

c. "My baby will probably start walking later than my other children."

The mother of a preterm infant weighing 1200 g is worried because her baby does not seem to respond to her. The nurse's best response is that: a. she should stroke her baby as well as talk to him .b. infants this young cannot sense the presence of others. c. her baby is too immature to tolerate much stimulation. d. the baby will respond to her better just before feeding.

c. her baby is too immature to tolerate much stimulation.

This is typically manifested by white patches in the mouth that resemble milk curds.

candidiasis, which may also occur in the infant with AIDS

Intellectual disability is associated with the infection.

cytomegalovirus, herpes (with disseminated infection), rubella, toxoplasmosis

Steven's bilirubin level continues to rise and becomes dangerously high. What complication can occur with dangerously high levels of bilirubin?

High bilirubin levels may cause kernicterus, with pos-sible bilirubin encephalopathy as bilirubin deposits cause staining of the brain. Bilirubin encephalopathy has a high mortality, and survivors may suffer cerebral palsy, mental retardation, hearing loss, or other neurologic and develop-mental problems.

Respiratory distress syndrome in infant with diabetic mothers

High fetal insulin levels interfere with surfactant production.

Why is proper hydration important to maintain good respiratory status?

Hydration keeps secretions thin, so they are more easily removed.

Why is phototherapy begun at lower bilirubin levels if the infant is preterm rather than full-term?

Bilirubin encephalopathy is more likely to occur at lower bilirubin levels in the preterm infant than in the term infant.

What is the relationship among bilirubin, jaundice, kernicterus, and bilirubin encephalopathy?

Bilirubin is the waste product of excess erythrocyte break-down after birth. Jaundice is the staining of the skin and sclerae by bilirubin. Kernicterus occurs when the bilirubin levels are high enough to stain the brain tissue. Bilirubin encephalopathy is an extension of kernicterus to include damage to brain tissue by the bilirubin staining.

Why are tests for drug levels often needed for antibiotics?

Blood is analyzed at the highest (peak) and lowest (trough) levels to provide a basis for any needed changes in dosage and to prevent toxic effects on body tissues.

bilirubin encephalopathy

Brain damage resulting from deposits of bilirubin

What are some possible complications of an exchange transfusion?

Complications of exchange transfusion may include infec-tion, hypervolemia, hypovolemia, cardiac dysrhythmias, and hypocalcemia.

transient tachypnea of the newborn

Condition of rapid respirations caused by inadequate absorption of fetal lung fluid

list signs of overhydration.

- increased urine output with below-normal specific gravity - edema; -too-rapid weight gain - bulging fontanel - decreased blood sodium, protein, and hematocrit.

What advantages do nursing and breast milk have for the preterm infant?

-Breast milk has immunologic benefits(igA) - it is more easily digested - it provides enzymes, hormones, and growth factors - it causes less stress because the baby can better regulate respirations and suckling - the mother's body keeps the baby warm.

Describe the typical appearance of a macrosomic infant of a diabetic mother (IDM).

-Length and head circumference are usually normal for the gestational age. -The face is round and red, the body is obese, and muscle tone is poor. -The infant is irritable and may have tremors when disturbed.

List signs of dehydration

-decreased urine output - increased weight loss - increased urine specific gravity - dry skin or mucous membranes - sunken fontanel - poor tissue turgor - increased blood sodium, protein, and hematocrit.

What factors make fluid and electrolyte balance difficult in the preterm infant?

-greater water loss through the thin, permeable skin -non-flexed positioning that increases insensible losses - drying effects of outside heat sources - rapid respiratory rate and use of oxygen - poor ability of kidneys to concentrate or dilute urine before 35 weeks of gestation - poor ability of kidneys to regulate electrolytes

List factors that make newborns more vulnerable to sepsis neonatorum.

-immune system immaturity, with a slower reaction to invading organisms - poor localization of infection that allows more extensive spread of infection - less effective blood-brain barrier

List infant behaviors that should cause a nurse to suspect prenatal drug exposure.

-infants appear hungry, but suck and swallow are poorly coordinated - frequent regurgitation, vomiting, and diarrhea - signs typical of hypoglycemia but with a normal blood glucose level - restlessness - failure to gain weight

What is the purpose of giving an infant a pacifier when gavage feeding?

-is a way to provide breastmilk or formula directly to your baby's stomach. A tube placed through your baby's nose PURPOSE: -association of the comfort of fullness with sucking; -preparation for nipple feeding

What factors typically increase a preterm infant's risk for infection?

-maternal infection - incomplete passive antibody trans-fer from the mother during the third trimester - immature immune response - therapeutic procedures that are often invasive and damage their delicate skin

What are the possible reasons why a preterm infant will need intravenous or gavage feedings?

-poor suck, swallow, and breathing coordination - immature gag reflex - high expenditure of energy for sucking related to the nutrients ingested

What signs suggest development of respiratory distress syndrome?

-tachypnea - nasal flaring - retractions - cyanosis - grunting on expiration - decreased or wet breath sounds - acidosis with hypoxemia - chest x-ray film showing "ground-glass" appearance or atelectasis

Describe measures to evaluate fluid status in the preterm infant.

-weighing diapers to determine the difference between the dry weight and the wet weight - collecting urine with cotton balls at the perineum to check specific gravity - weighing the unclothed infant daily or twice daily on the same scale at the same time of day

What are the two possible consequences for a postmature fetus?

1. placental deterioration with chronic hypoxia, weight loss, oligohydramnios, and meconium passage into the amniotic fluid 2. continued placental function, with continued growth that increases the risk for birth injury or cesarean birth

How can diabetes cause both intrauterine growth restriction and large-for-gestational-age infants?

If the diabetic woman has vascular changes, placental blood flow may be reduced, interfering with fetal growth. If the diabetic woman does not have vascular changes and her glucose levels are poorly controlled, she transfers large amounts of nutrients to the fetus. The fetus secretes large amounts of insulin to metabolize these nutrients, resulting in macrosomia.

What is the difference between primary and secondary apnea? Which is more ominous(bad)? Why?

In primary apnea, the infant may respond to stimulation when respirations cease. In secondary apnea, the infant does not respond to stimulation and loses consciousness. Secondary apnea is more ominous because stimulation is not enough to reverse it, blood oxygen levels decrease further, and the infant loses consciousness.

asphyxia

Insufficient oxygen and excess carbon dioxide in the blood

Hypoglycemia in infant with diabetic mothers

Maternal glucose supply ends, but the infant temporarily continues a high level of insulin production.

containment

Method to increase comfort in infants by swaddling

case study: What other assessments should be performed?

Monitoring of Steven's bilirubin level and skin color for jaundice are essential related assessments.

hypocalcemia in infant with diabetic mothers

Parathyroid hormone production is reduced.

Identify the required nursing interventions for Steven once treatment for jaundice has begun.

Nursing interventions related to phototherapy include the following: Cover the infant's closed eyes with patches to prevent light damage. Check placement of the patches hourly. Cover the reproductive organs with a diaper or other covering. Change the infant's position every 2 hours to distribute light exposure evenly over the skin surface. Check the fiber-optic blanket at the same intervals to ensure maxi-mum exposure of the skin surface. Check the infant's temperature every 2 to 4 hours. Place a skin probe on the infant if he or she is in an incubator. Monitor intake and output. Weighing diapers is the most accurate output measurement. Remove the infant from the lights as little as possible, such as for feeding or other care. This will not be neces-sary if a phototherapy blanket is used.

Meconium Aspiration Syndrome

Obstruction and air trapping caused by meconium in the infant's lungs, which may lead to severe respiratory distress. Most often in infants who are postterm, SGA, ad compromised before birth by placental insufficieny or cord compression CAUSE:MAS most often occurs due to asphyxia and acidosis caused by hypoxia, or when the infant takes their first breath S/S: signs of respiratory distress, GFR, tachypnea, cyanosis, nail skin and cord stained with meconium management: warmed humidified oxygen or extensive therapy with mechanical ventilation, if infant with depressed respirations and HR less than 100 endotracheal tube is used to remove as much meconium as possible nursing considerations: ensures equipment suctioning and oxygen functions properly , infant closely observed for for lung infection

What is the purpose of an exchange transfusion?

Performed when phototherapy is not able to decrease dangerous high bilirubin levels quickly enough. This treatment removes sensitized red blood cells, maternal antibodies, and unconjugated bilirubin and correct severe anemia Exchange transfusion replaces the infant's blood that has high levels of bilirubin, low erythrocytes, and many sensitized erythrocytes with blood that has normal levels of these components. In addition, the blood that replaces the infant's blood is not sensitive to the circulating antibodies from the mother that have destroyed the infant's own erythrocytes.

Distinguish periodic breathing from apneic spells.

Periodic breathing is cessation of breathing for 5 to 10 seconds without other changes apneic spells last more than 20 seconds and/or are accompanied by cyanosis and bradycardia.

case study: Twenty-four hours after birth, Steven's bilirubin level is 13.5, and his skin is jaundiced. What treatment does Steven require at this time? How does the treatment affect his bilirubin level?

Phototherapy is the appropriate treatment at this time. The light causes bilirubin in the skin to change into a water-soluble form that can be excreted.

polycythemia in infant with diabetic mothers

Poor oxygenation requires that the fetus make more erythrocytes.

Coombs test

a blood test to diagnose hemolytic anemias in a newborn

bronchopulmonary dysplasia

Pulmonary condition resulting from prolonged use of supplemental oxygen

What are the possible side effects of this treatment?

Side effects may include frequent loose, green stools; a tanned appearance in dark-skinned infants; skin rash; or temporary lactose intolerance.

neonatal abstinence syndrome

Signs exhibited by the newborn exposed in utero to maternal substance abuse

List signs of neonatal hypoglycemia.

Signs include jitteriness, tremors, diaphoresis, rapid respi-rations, low temperature, and poor muscle tone.

How does the newborn manifest infection compared with an older child? Why is it particularly important to identify newborn sepsis early?

Signs of infection are often difficult to analyze. - They include temperature instability, respiratory problems, and changes in feeding habits or behavior. -Septic shock can develop quickly.

What treatment should Steven receive at this time to lower his bilirubin levels? Phototherapy has not worked

Steven should have an exchange transfusion to replace blood that has a high bilirubin level because of massive erythrocyte destruction with blood that is not affected by maternal antibodies in Steven's system. It is essential to prevent kernicterus and possible encephalopathy

What is the difference between symmetrical and asymmetrical intrauterine growth restriction (IUGR)?

Symmetrical: -infant is smaller than normal for gestation but head, chest, length, and weight are proportionate -problem began early in pregnancy. Asymmetrical - head, chest, and length are normal but weight is decreased - problem began during second half of pregnancy. -Infants who have symmetrical growth retardation are more likely to have long-term consequences.

How is an exchange transfusion performed?

The exchange transfusion is performed by removing 5 to 10 ml of Steven's blood and replacing it with an equal amount of donor blood. This process is continued until approximately twice his blood volume has been exchanged.

What are the expected results of the transfusion?

The expected results are that approximately 85% of Steven's erythrocytes will be replaced and the bilirubin will be reduced to approximately 45% of the pre-exchange level.

Why are gavage feedings sometimes needed for the drug-exposed infant, even if born at term?

The infant has poor coordination of suck and swallow, reducing actual milk intake. At the same time, energy expenditure is high because of excess activity.

What is the nurse's role in an exchange transfusion?

The nurse's role in the procedure is to prepare equipment and the blood, assess the infant during and after the proce-dure, and keep accurate records of blood withdrawn and infused. The transfusion is done under a radiant warmer

case study :Which of the information in the previous scenario indicates a pathologic condition?

The positive Coombs' test performed on cord blood obtained at birth indicates that antibodies from the mother have attached to the infant's red blood cells.

Why is the prone position not advised for normal newborns but good for the preterm infant?

The prone position is associated with an increased inci-dence of sudden infant death syndrome (SIDS). However, the prone position allows the immature preterm infant to use respiratory muscles more efficiently, reduces respira-tory effort, and increases oxygenation and lung compliance.

What blood type should be used for Steven's treatment and why?

Type O Rh-negative blood that is crossmatched to be com-patible with the mother's is transfused. The transfused blood is not affected by the maternal antibodies circulating in Steven's system.

persistent pulmonary hypertension

Vasoconstriction of the infant's pulmonary vessels after birth

Persistent Pulmonary Hypertension

Vasoconstriction of the infant's pulmonary vessels after birth prevent decrease of vascular resistance of the lungs after birth and normal changes to neonatal circulation are impaired. Risk factors: occurs in infants who are preterm, late preterm, or term. Due to abnormal lung development, maternal use of NSAIDS or SSRIs. S/S: develops signs within 24 hrs after birth. Tachypnea, respiratory distress, progressive cyanosis, O2 sat decreased, CO2 increased, acidosis is present management: sedation, high frequency ventilation, surfactant therapy , and inhaled nitric oxide may be necessary nursing consideration: because infants become hypoxic with activity and other stimuli handling and noise are kept to a minimum, Thermoregulation , assess hypoglycemia

Choose the caregiver teaching that is most appropriate for the infant who was exposed to cocaine prenatally. a. Breastfeeding is especially important to the infant's recovery from prenatal drug exposure .b. Align the infant's face with yours to allow prolonged eye contact that better facilitates bonding. c. Do not burp your baby until at least 1 ounce of formula has been taken. d. Swaddle your baby with arms and legs flexed to reduce startling.

d. Swaddle your baby with arms and legs flexed to reduce startling.

The nurse notes that a 24-hour-old infant is lethargic and her temperature is below normal, a change from an earlier assessment that was normal. Her mother states that she did not breastfeed well and that the infant spit up the small amount she had ingested. The nurse's next action should be to: a. reassure the mother that infants are often sluggish this soon after birth. b. feed the infant formula to determine accurately how much intake she is getting. c. determine whether there is jaundice over the thoracic and abdominal areas. d. assess for signs of sepsis and report assessments to the physician.

d. assess for signs of sepsis and report assessments to the physician

2. If meconium is present in the amniotic fluid, the infant's mouth and pharynx should be suctioned after the head is born but before the rest of the body. The primary reason for this action is to: a. limit transfer of infectious substances to the lower airways .b. reduce the likelihood that secondary apnea will occur. c. prevent persistence of abnormal cardiac shunts. d. avoid drawing meconium into the lower airways with the first breath.

d. avoid drawing meconium into the lower airways with the first breath.

4. Discharge teaching for the parents of an infant with bronchopulmonary dysplasia should emphasize: a. that recurrent grunting and retractions are common. b. the importance of providing enzyme formula supplements. c. careful handling to prevent pulmonary hemorrhage. d. managing equipment for oxygen supplementation.

d. managing equipment for oxygen supplementation.

Transient Tachypnea of the Newborn

develops rapid respirations after birth when inadequate absorption of fetal lung fluid occurs(C-section). Condition resolves within 24-72 hrs risk factors: C-section births, perinatal asphyxia, rapid delivery, maternal diabetes, Exact cause is unknown Manifestations: respirations 60-120 within hrs of birth GFR,mild cyanosis theraupetic management:oxygen for cyanosis, gavage feeding while RR is high to prevent aspiration and conserve energy nursing management: similar to that of respiratory care of the preterm infant

Antibiotic prophylaxis given soon after birth can prevent blindness.

gonorrhea, chlamydia

Antibiotics may be given to high-risk mothers in labor or to an infant after birth.

group B streptococcal infection at 36 weeks

which Infection is preventable through immunization.

hepatitis B, rubella

Maternal antiviral treatment during pregnancy can reduce transmission to infant.

human immunodeficiency virus/AIDS

Early screening and treatment for phenylketonuria (PKU) are necessary to prevent

intellectual disability

Why is the postmature infant likely to have problems with Thermoregulation

little insulating subcutaneous fat

physical characteristics postterm

loose skin dry and peeling skin meconium staining

Formulate a simple explanation about phototherapy to give to parents of a jaundiced newborn. Include in your explanation why the treatment is needed, how it works, and what precautions are needed to prevent injury.

phototherapy is the most common treatment of jaudice and involved placing theinfant under special light. During phototherapy bilirubin in the skin absorbs the light and changes into watersoluble products this products do not require conjugation by the liver and can be excreted in the bile and urine. Side effects of phototherapy: frequent loose green stools due to the increased bile flow Frequent stool can cause insensible water loss so 25% increase in fluid intake is needed

Why is the postmature infant likely to have problems with Hyperbilirubinemia

polycythemia secondary to intrauterine hypoxemia, with more erythrocyte breakdown after birth

Why is the postmature infant likely to have problems with hypoglycemia

poor glycogen stores at birth

List common measures to help the preterm infant maintain thermoregulation.

radiant warmers, incubators, warmed oxygen, measures to reduce air currents, transparent plastic blanket over the radiant warmer bed, keeping portholes of incubators closed as much as possible, heated blankets and hats when out of the incubator or radiant warmer, padding surfaces with warmed blankets when procedures are performed

Why does the IDM(infant diabetic mother) with polycythemia require adequate hydration?

to prevent sluggish blood flow and ischemia to vital organs

physical characteristics preterm,

underdeveloped flexor muscles poor muscle tone no subcutaneous fat abundant vernix caseosa