Newborn (At Risk, Module 12)
Assessment signs of cold stress
low temp, increased RR, hypoglycemia respiratory distress metabolic and respiratory acidosis
Risk factors for LGA
maternal diabetes multiparity previous macrosomic baby prolonged preg.
Assessment findings with polycythemia
may be asymptomatic if symptoms —> red ruddy skin, cardiac overload, hyperbilirubinemia, tachycardia, increased RR, resp. problems, grunting, tachypnea
A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning a safe feeding technique for this infant?
"Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."
An abandoned infant has been brought to the hospital. Ophthalmia neonatorum is diagnosed. What is the nurse's estimate of the infant's age?
3-4 days
Appropriate PaO2 to maintain with oxygen administration
50 > PaO2 > 100
Moderate hypothermia in neonate temps
89.6-96.6
Mild hypothermia in neonate temps
96.8-97.5
Severe hypothermia in neonate temps
< 89.6
Large for gestational age (LGA) =
> 90th percentile for gestational age
What is hyperbilirubinemia?
A decreased ability of bilirubin to bind to albumin resulting in an increase of bilirubin in the fetal blood (includes both physiological and pathological jaundice)
A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause?
ABO incompatibility
Complications of meconium aspiration syndrome?
Airway obstruction Hyperinflation of the alveoli due to the trapping of air Chemical pneumonia Decreased surfactant proteins Hemorrhagic pulmonary edema (interferes w/surfactant production)
Risks from postmaturity
Altered O2/nutrient transport in the placenta = increased risk for hypoxia and hypoglycemia at the onset of labor If placenta continues proper function = LGA baby Increased risk for macrosomia
A nurse inserts a nasogastric tube into a preterm infant's esophagus for feedings. Which assessment findings signify correct placement of the tube?
Aspiration produces a small quantity of light-yellow or light-green liquid; Testing of the aspirate with the use of a Nitrazine strip reveals that the gastric fluid is acidic
A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant?
Assess BG
Assessment of asphyxia
BPPs during pregnancy (shows risk for asphyxia) fetal pH samples fetal HR APGAR scores Low O2 saturation
A neonate born at 35 weeks' gestation has Apgar scores of 8 and 9. At 4 hours of age the newborn begins to experience respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. What problem does the nurse suspect?
Bacterial sepsis
An infant is admitted to the nursery after a difficult shoulder dystocia vaginal birth. Which condition should the nurse carefully assess this newborn for?
Brachial plexus injury
What is important to include during preterm neonate feedings?
Breaks - Pace feeding and allow for breathing breaks since preterm neonates may become fatigued during feedings
The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed?
Buccal smear
Signs of periventricular leukomalacia?
CNS depression, lethargy, hypotension After 6-10 weeks = abnormal Moro reflex, hypertonia, irritability, extension of legs, increased arm flexion
A nurse is caring for a newborn whose mother is suspected of having drug addiction. What should the nurse do to most accurately confirm that the newborn may be at risk for withdrawal?
Collect the newborn's urine by applying a collection bag to obtain a sample for testing
An infant is born with a bilateral cleft palate. Plans are made to begin reconstruction immediately. What nursing intervention should be included to promote parent-infant attachment?
Demonstrate acceptance
Signs of asphyxia
Depressed respiration Hypotonia white/blue color bradycardia poor reflex response low APGAR scores
Assessment of postmaturity
Dry, peeling, cracked skin Lack of vernix Profuse hair Long fingernails Thin, wasted appearance Meconium staining (green or yellow staining on the infant's skin, nail beds, or umbilical cord) Hypoglycemia Poor feeding behavior
Stimulates production of red blood cells if indicated in preterm
Erythropoietin
Hydramnios is diagnosed in a primigravida at 35 weeks' gestation. For what condition should the nurse assess the newborn?
Esophageal atresia (because fetus doesn't swallow amniotic fluid)
An infant is born precipitously in the emergency department. What should the nurse's initial action be?
Establish an airway for the newborn
Neonates have difficulty maintaining their body temperature; however, their bodies have several mechanisms to help them do so. Which ones should a nurse remember when caring for the newborn?
Flexed fetal position, brown fat metabolism, peripheral vasoconstriction
When is the nasal cannula used?
For babies that can maintain O2 saturation with nasal cannula
Assessment of PDA
Heart murmur at upper left sternal border active precordium widened pulse pressure with decreased diastolic BP tachycardia/tachypnea recurrent apnea increased work of breathing bounding pulse difficulty weaning from ventilator support increased O2 demand or ventilation confirmation by echocardiogram chest X-ray shows increased pulmonary vasculature, pulmonary edema, mild enlargement of heart
Why is the nasal CPAP used?
Helps to maintain and expand alveoli
Consequences of cold stress
Hypoglycemia (metabolic rate increases, glycogen stores used up) Metabolic acidosis (brown fat metabolized) Hypoxia
Metabolic risk signs
Hypoglycemia, hypocalcemia, hyperbilirubinemia, temperature instability
The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol spectrum disorder (FASD) in the newborn?
Hypotonia, hypoplastic maxilla, small upturned nose
Meds for PDA
Indomethacin - administered to facilitate closure and decrease risk of intraventricular hemorrhage diuretics
Shortly after birth a newborn is found to have Erb palsy. Which condition does the nurse suspect caused this problem?
Injury to brachial plexus during birth
A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching; seizures; cyanosis; abnormal respirations; and a short, shrill cry. Which complication does the nurse suspect?
Intracranial hemorrhage
Assessment findings for SGA
Large head compared to body long nails large anterior fontanel decreased wharton's jelly thin extremities and trunk loose skin due to lack of SQ fat skin that may be dry/flaky/meconium stained Weight/head circumference/length < 10th percentile (if symmetric) Head circumference/length appropriate but weight < 10th percentile (asymmetric) RDS may occur Hypothermia Polycythemia
Why is there a greater risk for cold stress in the preterm infant?
Larger surface area to body mass ratio Decreased amounts of insulating fat Thinner, immature skin with blood vessels near the surface Poor muscle tone Little/no brown fat fluid loss = evaporative heat loss Limited pulmonary vasoconstriction, peripheral vasoconstriction, glycogen stores
Extremely low birth weight =
Less than 1000 grams at birth
Assessment of infants of mothers w/ type 1 diabetes
Macrosomia Fractured clavicle and brachial nerve damage r/t should dystocia Hypoglycemia Hypocalcemia Hypomagnesemia Polycythemia Hyperbilirubinemia Low muscle tone Poor feeding abilities
A preterm newborn is given oxygen by way of a hood. What should the plan of care for this neonate include?
Make sure it's warmed + humidified
Nursing actions w/hypoglycemia
Monitor BG readings with feedings Monitor BG levels Calculate appropriate caloric requirements
A newborn's birth was prolonged because the fetal shoulders were very wide. Which reflex does the nurse anticipate a problem with?
Moro
Complications of neonatal chlamydial infection
Neonatal conjunctivitis and pneumonia
Risks of women who use drugs, alcohol, and tobacco
No or inadequate prenatal care Inadequate prenatal weight gain Sexually transmitted infections Obstetrical complications (e.g., preterm labor and abruptio placentae) Severe mood swings
A nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. What blood type does the mother usually have to cause this incompatibility?
O
An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant?
Obtaining heel blood to check for BG
A newborn is admitted to the nursery. The newborn weighs 10 lb, 2 oz (4592 g), which is 2 lb (907 g) more than the birthweight of any of the neonate's siblings. Which intervention should the nurse implement in relation to this baby's birth weight?
Perform serial glucose readings
Risk factors for BPD
Prematurity RDS O2 toxicity Intubation Assisted ventilation with positive pressure Lower gestational age and birth weight (< 32 weeks) infection pulmonary vascular damage secondary to excessive fluid administration, right-to-left shunting, patent ductus arteriosus, increased airway resistance
A client's membranes rupture during the transition phase of labor, and the amniotic fluid appears pale green. What priority intervention for the infant can the nurse anticipate implementing upon delivery?
Providing for suctioning of the oropharynx as the head emerges
The nurse is assessing a newborn with exstrophy of the bladder. What other defect is often associated with exstrophy of the bladder and may be of concern to the nurse?
Pubic bone malformation
The nurse concludes that a couple with a newborn with Erb palsy has an accurate understanding of the infant's prognosis. What should be taught about correction of this condition?
Recovery usually occurs in about 3 months.
Nursing actions for ROP
Reduce risk: admin O2 to maintain pulse ox parameters, use O2 blenders/calibrating systems, avoid bright lights
complications of neonatal hypoxia
Respiratory Acidosis Organ Damage (NEC, PDA, IVH) Anemia Polycythemia
Assessment of RDS
Respiratory Distress (tachypnea, seesaw breathing, retractions, grunting, nasal flaring, grey/dusky color, increased O2 requirements) Decreased breath sounds (atelectasis) Lethargy Hypotonia Hypoxemia (PaO2 < 50) Acidosis
Nursing actions for persistent pulmonary HTN of the newborn?
Review hx Assess for resp. distress, meconium aspiration, clinical manifestations Admin O2 and mechanical ventilation Monitor VS/pulse ox anticipate placement of umbilical catheters Admin IV fluids Admin meds Monitor labs Keep handling/treatments/suctioning/stimulation to a minimum (causes decreased PaO2 and vasoconstriction) Emotional support
Maternal risk factors for the neonate
SES, environmental exposure, preexisting conditions (heart disease, diabetes, HTN, renal problems), age, parity, pregnancy complications
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother is by performing a heel stick blood test on the newborn. What specifically does this test determine?
Serum glucose
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?
Suction the mouth
During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn?
Suctioning the airway
Which clinical finding does the nurse anticipate regarding the alveoli in the lungs of a 28-week-gestation neonate?
Tendency to collapse w/ each breath
A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus?
Tense fontanels (excess CSF), high-pitched crying, a defect in the lumbosacral area (Hydrocephalus complicates approximately 80% of lumbosacral meningomyeloceles)
A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure (CPAP) therapy by way of an endotracheal tube. The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action?
The infant may have a pneumothorax, and the health care provider should be called so that corrective therapy can be started immediately.
Intrapartal exposure of infection
The neonate is exposed to infection during the birth process (e.g., herpes virus)
What is Meconium Aspiration Syndrome?
The presence of meconium fluid in the neonate's lungs can cause a partial obstruction of the lower airways that leads to a trapping of air and a hyperinflation of the airway distal to the obstruction, causing uneven ventilation. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant action. These changes place the neonate at risk for atelectasis
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)?
Thin upper lip, small upturned nose, smooth ridge above upper lip
A male newborn has been exposed to human immunodeficiency virus (HIV) in utero. Which assessment supports the diagnosis of HIV infection in the newborn?
Thrush that does not respond readily to treatment
The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties?
Tongue thrust
What maternal condition would cause the nurse to expect signs of respiratory distress syndrome (RDS) in a neonate?
Type 1 Diabetes
What should be done during gavage feedings to promote nutritional transition?
Use nonnutritive sucking with a pacifier during gavage feedings
Which intervention should the nurse take immediately when an apnea monitor sounds an alarm 10 seconds after cessation of respirations?
Use tactile stimulation on chest/extremities
Symptoms of subarachnoid hemorrhage?
Usually none, but may show seizures
A preterm newborn appears to have a strong sucking reflex. How should the nurse plan to feed the infant to prevent respiratory compromise?
With small amounts of breast milk at each feeding
Asymmetric IUGR
a disproportional reduction in the size of structures and organs, results from maternal or placental conditions that occur later in pregnancy and impede placental blood flow Causes: preeclampsia, placental infarcts, severe maternal malnutrition
Symmetric IUGR
a generalized proportional reduction in the size of all structures and organs except for heart and brain, is the result of a condition that occurs early in pregnancy and affects general growth Causes: exposure to teratogens, congenital infections, genetic problems
GI risk signs
abnormal feeding reflexes, vomiting, distention, stool problems (blood?), failure to pass stool
What is Hypoxic-Ischemic Encephalopathy?
abnormal neurologic behavior resulting from hypoxic-ischemic event
What is retinopathy of prematurity?
abnormal vascularization and associated bleeding, and fluid leakage, cause scar tissue that pulls and distorts the retina and displaces the macula. It also causes retinal folds and can lead to retinal detachment
Signs of NEC
abnormal vital signs, abdominal distention (increase in abdominal circumference), abdominal discoloration, bowel loops, feeding intolerance, emesis, residuals, bloody stools, and behavioral changes
Risk factors for postmaturity
anencephaly hx of post term pregnancies first pregnancy grand mulitparity
First step in respiratory assessment at birth
are they clearing meconium? are they breathing/crying? look at muscle tone and color, term gestation? (if appropriate, warm and dry and clear airway)
When should infant BG be assessed?
assess within 1 hours of birth (30 mins if diabetic mom) and prior to feedings
What is bronchopulmonary dysplasia?
chronic lung problem involving decreased lung compliance and pulmonary function secondary to fibrosis, atelectasis, increased pulmonary resistance, and over-distention of the lungs primarily due to prolonged mechanical ventilation and oxygenation
Anemia in the newborn
fetal Hgb < 14
Risk factors for elevated unconjugated bilirubin
fetal hypoxia, ABO or Rh incompatibilities, certain ethnicities, oxytocin use, delayed cord clamping, mom is breastfeeding, bruising, young gestational age, mom had diabetes, baby experienced asphyxia
if cyanotic, what do you do?
give supplemental O2
With Rh+ father and Rh- mother = potential complication for what?
hemolytic disease of newborn
Main cause of ROP
high concentrations of O2 admin
Assessment of neonatal hypoglycemia
lethargy jitteriness poor feeder (vomit frequently) relatively pale bouts of apnea/irregular respirations hypotonia seizures exaggerated reflexes
Respiratory distress syndrome
life threatening lung disease resulting from undeveloped/small alveoli and insufficient surfactant causing decreased alveoli surface tension and atelectasis (collapsed lungs) **increased in prematurity**
Primary reason for LBW
prematurity
Risk factors for CNS injuries
prematurity birth trauma breech delivery / malpresentations precipitous labor difficult labor/traumatic delivery/use of forceps hypoxia, asphyxia, hypotension, ischemia, resp. distress - maternal causes - cardia arrest, shock - placental abruption, cord prolapse, uterine hyperstimulation - fetal causes - cardiac arrhythmia
Risk factors for CNS problems
preterm / experienced labor trauma / precipitous delivery / hypoxic episodes
if persistently cyanotic after O2, what do you do?
provide positive pressure ventilation
What is a neutral thermal environment?
range of thermal environment in which the body temp. is normal, O2 and caloric consumption is minimal, and the least amount of metabolic is expended
Position neonate in ____ position to enhance oxygen and gastric emptying
side lying/prone
Nonpharmacological interventions for pain
swaddling, positioning, kangaroo care, and therapeutic touch, and decrease environmental stimulus
Causes of periventricular leukomalacia?
systemic hypotension, apnea + bradycardia r/t poor cerebral perfusion, infection of chorion
Where is Vit K administered?
vastus lateralis
Small for gestational age (SGA) =
weight < 10th percentile for gestational age
Weight risk signs
weight < 2500 g (LBW)
Medications to treat withdrawal in neonates include:
■ Methadone, morphine, paregoric, tincture of opium, clonidine, and diazepam, for opioid withdrawal ■ Benzodiazepines to treat withdrawal from alcohol ■ Phenobarbital for hyperactive behavior associated with narcotic withdrawal; also used for withdrawal from non-narcotic agents ■ Chlorpromazine for babies exhibiting gastrointestinal and CNS effects of narcotic withdrawal
What is necrotizing enterocolitis?
GI disease that results in inflammation and necrosis of the bowel, usually the proximal colon or terminal ileum
A newborn is found to have a diaphragmatic hernia. What is the immediate intervention after the neonate is admitted to the neonatal intensive care unit?
Gastric decompression via NG tube
Prevention of hemolytic disease of the newborn
Give mom Rhogam within 24 hours of birth (if indicated)
primary cause of meningitis and sepsis
Group B strep
Neonatal signs of toxoplasmosis
Growth retardation, hydrocephalus, chorioretinitis, thrombocytopenia, jaundice, and fever
A newborn has just begun to breast-feed for the first time. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse best intervene at this time?
Halt the feeding and notify the healthcare provider to evaluate the infant for a tracheoesophageal fistula
When to transition neonate to oral feedings from tube feedings?
Has cardiorespiratory regulation Demonstrates a coordinated suck, swallow, and breathe Demonstrates hunger cues such as bringing hand to the mouth, sucking on fingers Maintains a quiet alert state
The nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease?
Having sex w/ many partners
What is hemolytic disease of the newborn?
Hemolytic disease of the newborn, also known as erythroblastosis fetalis, is an alloimmune condition that develops in a fetus, when the IgG molecules (one of the five main types of antibodies) produced by the mother pass through the placenta
Why is the OxyHood used?
Higher concentration and more readily available
When checking a newborn's reflexes, the nurse is unable to elicit one specific reflex response. This is not uncommon in neonates born vaginally in the breech presentation. How should the nurse attempt to elicit this response?
Holding the infant in the upright position while pressing the feet flat on the crib mattress
Transplacental transfer of infection
Infection, such as syphilis, is transmitted to the fetus through the placenta
A nurse is assessing a newborn whose mother had a precipitate birth at home. For which complication should the nurse assess the newborn?
Intracranial hemorrhage (no time for molding)
What is a Subarachnoid Hemorrhage?
Intracranial hemorrhage usually due to trauma in term neonate or hypoxia in preterm bleeding in subarachnoid space (most common)
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)?
Irritability, high pitched cry, ineffective feeding, bulging fontanels
The nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn?
Irritability, hypotonia, ineffective sucking
Which component of nursing care is most important for a newborn with respiratory distress syndrome (RDS)?
Keep the infant in a warm environment
What is the main complication of hyperbilirubinemia?
Kernicterus = abnormal accumulation of unconjugated bilirubin in the brain cells (toxic); leads to deafness, delayed motor skills, hypotonia, intellectual deficits
What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy?
LGA, near term
Complications of IUGR
Labor intolerance r/t placental insufficiency, inadequate nutrition/O2 reserves Meconium aspiration r/t asphyxia during labor Hypoglycemia r/t inadequate glycogen stores and increased metabolic demands Hypocalcemia r/t asphyxia (signs = jitteriness, tetany, seizures)
At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What is the nurse's priority action in response to this situation?
Suction and oxygenate
Assessment signs of hemorrhage in neonate
Sudden change in condition Bradycardia O2 desaturation Hypotonia Metabolic acidosis Shock Decreased Hct Full/tense anterior fontanel Hyperglycemia
The nurse is caring for a newborn with a caput succedaneum. What is the priority nursing action?
Support the parents
A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur?
The ribcage is not compressed and released during birth
What is a intracerebellar hemorrhage?
large bleed in center of brain common in preterm or low birth weight due to difficult delivery or breech presentation can cause neurological deficits
if apneic or HR < 100, what do you do?
provide positive pressure ventilation
Meds for persistent pulmonary HTN of the newborn?
Vasopressors (dopamine, nitroprusside) Vasodilators (prostaglandins, isoproterenol) Muscle relaxants (pavulon) sedatives and analgesics (morphine, Versed) antibiotics
Cold stress in the term newborn can cause peripheral vasoconstriction leading to ____
hypoxia
What is polycythemia?
increase in blood volume and Hct in newborns
Cold stress in the term newborn can cause an increased metabolic rate leading to ____
increased O2/glucose consumption
Cardiovascular risk signs
irregular HR/rhythm, pulse differences between upper/lower extremities, color changes (circumpolar cyanosis or central)
The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. How does the nurse explain the increased risk for hypothermia in preterm infants?
Lack the subcutaneous fat that usually provides insulation
The nurse must meet the hydration needs of a preterm infant. What should the nurse consider carefully regarding the preterm infant's kidney function?
Large amounts of urine are excreted
Nursing actions for NEC
Assess for abdominal distention, visible bowel loops, emesis, bloody stools Withhold feedings per order and obtain IV access Perform gastric decompression (orogastric tube connected to low suction) Monitor I&Os to maintain circulating blood volume prep for surgery
Nursing actions for hemorrhaging
Assess for changes in VS, behavior, neuro status = increased intracranial bleeding Reduce stress by maintaining dark/quiet environment Admin fluid volume replacement slowly to minimize fluctuation in BP
Administer _____ as per orders to treat pain associated with procedures that cause moderate to severe pain
Opioids
Management of asphyxia
CPR in absence of HR (or HR < 60) Encourage lung expansion Support CO and minimize O2 consumption Suctioning to prevent aspiration Maintenance of fetus in head down position before first breath Warm/dry Bag/valve mask if needed to push open alveoli (HR < 100) RR < 30 or HR < 60 needs resuscitation
Complications for LGA
CS operative vaginal delivery shoulder dystocia breech presentation birth trauma CPD hypoglycemia hyperbilirubinemia
An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. What is the priority nursing action?
Check for signs of pneumonia
Nursing interventions for BPD
Chest physiotherapy as ordered (vests can be used or cup hands to loosen secretions in chest) Resp. assistance and O2 therapy (gradual weaning from ventilation as ordered) bronchodilators (reduce bronchoconstriction) corticosteroids (reduce bronchospasms, edma, and inflammation of pulmonary tissue) diuretics (treat fluid retention and decrease pulmonary edema risk) Monitor I&O Meet nutritional needs **provide maximal nutrition with minimal fluid** High metabolic rate in these neonates
A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. Which condition does the nurse suspect?
Chlamydia infection
common forms of intracranial hemorrhage in the neonate (primarily during first week of life)
Periventricular/Intraventricular Hemorrhage
Ways to maintain NTE for premature neonate
Dry immediately after birth Keep head covered Plastic barriers Using a chemical warming mattress during resuscitation Prewarm radiant warmers, incubators, and linens A temperature control probe should be placed on the neonate's abdomen Double walled incubator Skin-to-skin care (kangaroo) if possible Weaning infants gradually from incubator to an open crib
Birth-related risk factors for the neonate
Dysmaturity, immaturity, physical disorders, congenital abnormalities, complications
Nursing interventions for polycythemia
Early ID with Hct screening and monitoring symptoms/distress
A preterm newborn is placed in the neonatal intensive care unit. What is the first concern that the nurse anticipates for this infant's mother?
Fear of touching the newborn
An infant born with hydrocephalus will be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home?
Fever accompanied by decreased responsiveness (shows infection)
Silverman Anderson Index of Respiratory Distress scoring
10 = bad; 0 = good
Neonatal signs of herpes virus type 2
Fever, coryza, tachycardia, and hemorrhage
An infant is born in the breech position, and assessment indicates the presence of Erb palsy (Erb-Duchenne paralysis). Which clinical manifestation supports this conclusion?
Flaccid arm with the elbow extended on the affected side
A newborn with a myelomeningocele is being transferred immediately from the birthing room to the neonatal intensive care unit (NICU). What is the initial nursing intervention?
Apply a sterile saline dressing
A newborn has an intracranial hemorrhage because of a tear in the tentorial membrane sustained during birth. Which clinical finding does the nurse expect the infant to display?
Abnormal breathing pattern
The nurse takes into consideration that the effect PKU has on the infant's development will depend primarily upon which factor?
Adherence to a corrective diet instituted early
Nursing actions for PDA
Admin O2/mechanical ventilation Restrict fluids Admin meds Monitor I&Os for fluid overload prepare the neonate and family for surgery
After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include?
Admin additional fluids q 2 hours
The nurse is caring for a preterm neonate who is receiving gastric feedings. Which neonatal clinical finding unique to necrotizing enterocolitis (NEC) leads the nurse to suspect that the neonate is experiencing this complication?
An increasing residual volume from earlier feedings without increasing intake indicates that absorption is decreasing, a sign of NEC
Signs of neonatal withdrawal
Apnea Behavior irregularities Diarrhea Dysmature swallowing Excessive crying Excessive/frantic sucking Excoriated skin Fever High-pitched cry Hyperreflexia Hypertonia Irritability/restlessness Lacrimation Nasal congestion Poor feeding Seizures Skin mottling Sleep problems Sneezing Sweating Tachypnea Tremors Vomiting Wakefulness Weight loss or failure to gain weight Yawning
Signs that bleeding is worsening
Apnea Increased need for ventilator support Drop in BP Acidosis Seizures Full/tense fontanels and rapid increase in head size Diminished activity or LOC
Assessment signs for NEC
Apnea, bradycardia, and tachycardia Respiratory failure Hypoxemia Unstable temperature Hypotension, shock Abdominal distention, bloody stools, abdominal tenderness, vomiting, increased gastric residuals, discoloration of abdomen, visible bowel loops Lethargy Abnormally high or low white blood cell count, thrombocytopenia Abnormal electrolyte levels Metabolic acidosis Abdominal xray = distention of intestines w/gas, gas in one part of intestines but lack in another, air in the wall of the intestines/portal venous system, dilated loops of bowel, air in abdomen
Respiratory risk signs
Apnea, tachypnea, flaring, retractions, seesaw breathing, grunting, abnormal ABGs
Nursing actions for neonatal infection
Assess maternal and neonatal histories for factors that may place a neonate at risk for infection, such as maternal Group B Streptococcus status Assess vital signs and adequacy of feedings, and monitor intake and output and weight, per agency protocol Assess neonate for signs of infection apnea, grunting, retractions, tachypnea, cyanosis hypothermia, fever, temp instability bradycardia, tachycardia, arrhythmias, hypo/hypertension, decreased perfusion tremors, lethargy, irritability, high-pitched cry, hypertonia, hypotonia, seizures, bulging fontanels poor feeding, vomiting, diarrhea, abdominal distention, enlarged liver/spleen rash, pustules, vesicles, pallor, jaundice, petechiae, vasomotor instability glucose instability, metabolic acidosis Notify the physician if the neonate demonstrates signs of infection. Early recognition and treatment of neonatal infection is important in preventing morbidity and mortality. Provide respiratory support as per orders. Monitor glucose and electrolytes. Obtain laboratory tests as per order. Assist with diagnostic tests such as lumbar puncture for CSF (CSF is obtained and sent to lab for a Gram stain and culture; Holding the infant still in a flexed position is imperative for a successful lumbar puncture) Administer antibiotics as per orders Administer intravenous fluid and parenteral nutrition as per orders Wash hands before handling equipment and caring for the neonate Provide parents with information about the neonate's status, infection prevention strategies such as handwashing before contact with the baby, and diagnostic tests and treatments as appropriate Include the following in discharge teaching for parents: identification of signs and symptoms of infection, what signs/symptoms should be reported to the physician, how to prevent infection, and scheduling a follow-up appointment before discharge
Nursing actions for infants of mothers w/ type 1 diabetes
Assess neonate for signs of respiratory distress, birth trauma, congenital anomalies, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia Monitor blood glucose per agency protocol (May require intravenous fluids along with feedings to maintain adequate blood glucose levels) Provide early and frequent feedings to treat and prevent hypoglycemia - May be passive, lethargic, and difficult to arouse - Oral feeding skills must be assessed and supported - Gavage feedings may be indicated Obtain laboratory tests as per orders Maintain a neutral thermal environment to reduce energy needs
Nursing actions for postmaturity
Assess: -Risk factors -Gestational age -Birth trauma if macrosomic -Resp. distress -Cyanosis -O2 saturation if resp. distress/cyanosis is present -Signs of meconium staining -BG levels -VS -Weight -Gross anomalies Monitor for signs of hypoglycemia (jitteriness, irritability, poor feeding, apnea, grunting, lethargy) Provide early/freq. feedings if resp. status is stable (reduce hypoglycemia risk) Monitor I&O (poor feeders = inadequate fluid intake?)
Nursing actions for meconium aspiration syndrome?
Assist w/ suctioning and resuscitation at time of delivery Physical assessment: - Resp. distress -Cyanosis -Complications of meconium aspiration syndrome (acidosis, hypoglycemia, hypocalcemia, pneumonia, pneumothorax, bronchopulmonary dysplasia, persistent, pulmonary hypertension) -Neurological problems secondary to asphyxia Admin O2/ventilation Monitor BG (compensatory increased metabolic rate increases risk for hypoglycemia) Manage ECMO
The nurse is assessing a newborn with a diaphragmatic hernia. What does the nurse expect to find?
Barrel chest and sunken abdomen with colicky pain and constipation
Factors that influence newborn outcome
Birth weight*** Gestational age*** Type/length of newborn illness Environment that they're born into Maternal factors Maternal/infant separation
Causes of newborn anemia
Blood loss (placental bleeding, intrapartal blood loss, birth trauma, cerebral bleeding) Hemolysis (blood incompatibilities ABO/Rh, infections) Impaired RBC production Physiologic anemia of infancy (normal to drop for first 6-12 weeks) - If significant —> iron supplements or fortification - Blood transfusion if severe (monitor signs of anemia and shock)
After a difficult vaginal birth, assessment of a full-term newborn reveals an unequal Moro reflex on one side and a flaccid arm in adduction. Which problem does the nurse suspect?
Brachial palsy
A client expresses a desire to breastfeed her preterm infant, who is being cared for in the neonatal intensive care unit. How should the nurse respond to this client's request?
By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion
A client expresses a desire to breast-feed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breast-feed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request?
By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired
The nurse suspects that a newborn's mother contracted rubella during the first trimester of pregnancy. Which newborn problems support this assumption?
Deafness, cardiac anomalies, congenital cataracts, microcephaly
A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. Which test result should the nurse anticipate for this infant?
Decreased pH
Advantages of kangaroo care
Decreases risk of low body temp Reduces illness, infection, pain perception Improves daily weight gain and attachment Decrease length of hospital stay
Signs of fetal alcohol syndrome
Distinctive facial features: small eyes, thin upper lip, and short nose Heart defects Joint, limb, and finger deformities Delayed physical growth, both intrauterine and post-birth Vision problems Hearing problems Mental retardation Behavior disturbances, such as short attention span, hyperactivity, and poor impulse control
Treats hypotension in preterm neonate
Dopamine or dobutamine
A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute?
Droplet
Assessment signs of prematurity
Early in gestation, resting tone and posture are hypotonic and extended The skin is translucent, transparent, and red Subcutaneous fat is decreased Lanugo is present between 20 and 28 weeks' gestation Creases on the anterior part of the foot are not present until 28-30 weeks Eyelids are fused in very preterm neonates (open 26-30 weeks) Overriding sutures are common among premature, low birth weight neonates The pinna of the ear is thin, soft, flat, and folded The testes are normally not descended, and are found in the inguinal canal Tremors and jittery movement may be noted The cry is weak Reflexes may be diminished or absent Immature suck, swallow, and breathing patterns are observed in very premature infants (may not be able to handle oral feedings) Apnea, cessation of breathing for at least 10-15 seconds, and bradycardia, heart rate less than 100 beats per minute, are commonly observed Hypotension may occur among extremely low birth weight infants Heart murmur may be present related to patent ductus arteriosus Anemia is common, especially among very low birth weight babies
A neonate begins to exhibit nasal flaring and grunting at 16 hours of age. What is the nurse's initial action?
Elevate the head of the crib
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?
Encouraging more frequent breastfeeding during the first 2 days
Two days after birth a neonate's head circumference is 16 inches (41 cm) and the chest circumference is 13 inches (33 cm). What does the nurse infer from these measurements?
Enlarged head size
Nursing actions with phototherapy
Expose entire surface of skin w/ coverage of genitals/buttocks/eyes No diaper/covering Photometer Assess bilirubin levels q 12 hours Prevent hypothermia/hyperthermia (take temp) May need additional fluids Assess skin regularly (watch for pressure areas) Assess redness of eyes or conjunctivitis when taking eye guards off Reposition q 2 hours Watch for complications
Why would IV nutrition be necessary in preterm infant?
Extremely LBW may lack ability to digest/absorb feedings and have an inability to suck/swallow/breathe
A neonate born at 39 weeks' gestation is small for gestational age. Which commonly occurring problem should the nurse anticipate when planning care for this infant?
Hypoglycemia
A small-for-gestational-age (SGA) newborn has just been admitted to the nursery. Nursing assessment reveals a high-pitched cry, jitteriness, and irregular respirations. With which condition are these signs associated?
Hypoglycemia
Risk factors for persistent pulmonary HTN of the newborn?
Hypoxia and asphyxia ** RDS, meconium aspiration, pneumonia Bacterial sepsis Delayed circulatory transition at birth caused by delayed resuscitation, CNS depression, hypothermia Hypothermia/hypoglycemia leading to acidosis Polycythemia or hyperviscosity of blood associated with premature closure of the ductus arteriosus or fetal systemic HTN Underdevelopment of pulmonary vessels associated w/congenital anomalies Abnormal development of pulmonary vessels associated w/intrauterine asphyxia or intrauterine meconium aspiration
A client exhibits oligohydramnios at 36 weeks' gestation. What newborn complication should the nurse anticipate?
IUGR
A client with chronic hypertension and superimposed preeclampsia gives birth at 39 weeks' gestation to a 4 lb 12 oz (2155 g) infant. What condition does the nurse anticipate when assessing this infant?
IUGR
Which characteristic that may pose a potential nutrition problem should the nurse identify in a preterm neonate?
Inadequate sucking reflex
A neonate born at 36 weeks' gestation, weighing 4 lb 8 oz (2041 g), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/hr. Why is it important for the nurse to check the neonate's voidings for specific gravity?
Infants under open radiant warmers are at risk for dehydration
Ascending infection
Infection ascends into the uterus related to prolonged rupture of membranes
Risk factors for jaundice
Infection, prematurity, mom w/diabetes, breastfeeding
Very low birth weight =
Less than 1500 grams at birth
Low birth weight =
Less than 2500 grams at birth
CNS risk signs
Lethargy, high pitched cry, jitteriness, seizures, bulging/depressed fontanels
Nursing management of RDS
Maintain patent airway (proper positioning of endotracheal tube) Monitor VS ((if HR < 100 bag, if < 60 do CPR)) Admin/monitor O2 as ordered (needs to be warmed and moistened) Maintain neutral thermal environment (to decrease work needed to breathe) Suction as needed (clear resp. tract) Monitor I&Os (increased risk for pulmonary edema with overhydration; dehydration impairs ability to clear mucus) Monitor weight Promote rest
The nurse who is caring for a 32-week appropriate-for-gestational-age (AGA) neonate develops a plan of care for the neonate. What is the priority intervention at this time?
Maintain respirations
The nurse is caring for preterm infants with respiratory distress in the neonatal intensive care unit. What is the priority nursing action?
Maintaining a high-humidity environment to promote gas exchange
Uteroplacental intrauterine hypoxia
Maternal oxygenation is normal but the utero-placental circulation is impaired - Abnormal placental attachment - Decreased placental blood flow (pre-eclampsia, placenta abruption) - Cord compression or accidents - Very long or difficult labor or delivery - High/low maternal blood pressure
What must the nurse be cautious of when suctioning the neonate?
May stimulate the vagus nerve causing bradycardia, hypoxemia, bronchospasm
A nurse is caring for a preterm infant with necrotizing enterocolitis (NEC). Which nursing intervention is most important for this infant?
Measuring abdominal girth frequently
Complications from postmaturity
Meconium aspiration Fetal hypoxia r/t placental insufficiency and decrease in amniotic fluid with increased risk for cord compression Neurological complications such as seizures r/t fetal asphyxia during labor/birth due to alteration in oxygenation Hypoglycemia r/t alteration in nutrient transport due to decreased placental function ing Hypothermia r/t lack of development of SQ fat and loss of fat due to insufficient nutrient transport Polycythemia (Hct> 65%) due to alteration in oxygenation Birth trauma r/t macrosomia
Assessment findings for meconium aspiration syndrome?
Meconium-stained amniotic fluid Meconium visualized below the vocal cords Green/yellowish discoloration of skin, nail beds, umbilical cord Resp. depression at the time of birth or within a few hours after birth Low Apgar scores Need for resuscitation after delivery due to perinatal depression Signs of resp. distress (nasal flaring, grunting, retractions) Chest may appear barrel shaped and over distended Expiration phase of breathing may be extended Diminished air movement Rales/rhonchi Xray shows atelectasis and hyperinflated areas through lungs ABGs show low PaO2 (despite 100% O2 admin) Respiratory/metabolic acidosis
Pre-placental intrauterine hypoxia
Mother is hypoxic which creates a hypoxic environment for the fetus - Too little O2 in mom's blood before/during birth - Women with congenital heart disease and/or chronic pulmonary disease - Acute resp. infections in pregnancy (pneumonia, bronchitis) - Maternal hematological disorders that affect oxygen transfer (iron deficiency anemia, sickle cell anemia, thalasemia)
Very premature =
Neonates born at less than 32 weeks' gestation
Premature =
Neonates born between 32 and 34 weeks' gestation
Late premature =
Neonates born between 34 and 37 weeks' gestation
Signs of Alcohol related neurodevelopmental disorder (ARND)
Neurological problems (e.g., poor hand-eye coordination and fine motor skills, and neurosensory hearing loss) Decreased cranial size, brain abnormalities Cognitive and behavioral problems
Flushed skin (Polycythemia), placid temperament, and limp muscles may be indicative of what in a newborn?
Newborn of Diabetic Mother
The nurse is caring for a newborn whose mother was prescribed an opioid analgesic throughout pregnancy. Which action should the nurse include in the plan of care?
Offering small, frequent feedings
Postplacental intrauterine hypoxia
Only the fetus is hypoxic due to a fetal problem - Fetal cardiac failure - Genetic/congenital abnormalities (airway malfunction, cardiac malfunction, etc.) - Fetal anemia
The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?
Opioid drug withdrawal
A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant?
Phenex and Lofenalac
Difference between physiological/pathological jaundice
Physiologic = adaptive, doesn't require treatment, occurs after 24 hours, esp. in preterms Pathologic = appears within 24 hours or persisting 14 days after birth, clay stools, urine staining clothes, levels rise hourly, caused by Rh incompatibiliity or erythroblastosis fetalis, diabetes, infection, drug use, hepatitis, metabolic/hematological disorders, sequestered blood may require phototherapy, exchange transfusions, albumin transfusions
The nurse is caring for a new mother who has a chlamydial infection. For which complications should the nurse assess the client's neonate?
Pneumonia, preterm birth, conjunctivitis
Risk factors for NEC
Prematurity is the most common risk factor for NEC Bacterial colonization can occur from contaminated nasogastric feeding tubes among premature neonates receiving formula Umbilical catheter placement
Barely visible areolae and nipples common in which age group?
Preterm
Caloric needs for preterm infant
Preterm infants require between 105 and 130 kcal/kg/day
Why should fluids be restricted in BPD and PDA?
Prevent pulmonary edema
Best treatment for RDS
Prevention!! (corticosteroids for lung development?, aggressively treating preterm labor?)
Risk factors for asphyxia
Problems during pregnancy (fewer reserves, less tolerance for birth) Non-reassuring FHR Difficult birth (forceps-delivery or vacuum delivery, meconium in amniotic fluid, apnea episode, white males gender, prematurity, SGA, lung abnormality, multiple gestation)
A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score?
Start resuscitation
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?
Protect the sac w/ moist sterile gauze
A nurse is planning to teach the parents of a preterm infant regarding the infant's nutritional needs. Some nutrients are required in greater quantities in a preterm infant than a full-term one. Which nutrients should the nurse include in the plan?
Proteins
If "No" to whether the neonate is clearing meconium, breathing/crying, showing appropriate muscle tone/color, and term gestation, then what is the next step?
Provide warmth, position and clear airway if necessary, dry, stimulate, reposition
A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions should the nurse implement to protect the infant under the oxygen hood?
Put a hat on the infant's head to prevent hypothermia
Giving too much O2 can cause what?
ROP (retinopathy of prematuriy), BPD (bronchopulmonary dysplasia)
What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?
Respiratory distress
In her 36th week of gestation, a client with type 1 diabetes delivers a 9 lb 10 oz (4366 g) infant via cesarean birth. For which condition should the nurse monitor this infant of a diabetic mother?
Respiratory distress syndrome
Nursing actions for CNS injury
Review maternal prenatal and intrapartal histories for risk factors Perform physical assessment of the neonate, including evaluation of tone, reflexes, and behavior Notify physician of abnormal findings Administer oxygen as per order Obtain laboratory tests as per order Ensure that ordered diagnostic tests are completed Assist with diagnostic procedures such as lumbar puncture Administer medications as per order Monitor temperature closely of infants undergoing cooling therapy Provide the family with support and information about their infant's status, treatment, and follow-up
Nursing actions for LGA
Review records for risk assess resp. status assess for birth traumas obtain BG + assess signs of hypoglycemia provide freq. feedings obtain/monitor Hct (increases risk for jaundice) assess skin color for signs of polycythemia perform gestational age assessment observe for jaundice
During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action should the nurse take?
Rewarm gradually
If BG < 40, what should we be concerned about?
Risk for cold stress
The parents of a preterm newborn visit the neonatal intensive care unit (NICU) for the first time. They are obviously overwhelmed by the amount of equipment and the tininess of their baby. What is the nurse's most appropriate response to their reaction?
Show the parents how to touch their baby
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis?
Shunting of blood from right to left
Assessment of cardiovascular system in preterm neonate
Signs of patent ductus arteriosus Murmurs Pulses Capillary refill
Treats metabolic acidosis in preterm neonate
Sodium bicarbonate
Administer ____ and promote _____ during painful procedures
Sucrose, nonnutritive sucking
Preterm discharge teaching
Teaching parents about infant feeding Teaching about use of any equipment, such as apnea monitors that may be needed to care for their infant at home Teaching parents how to perform treatments such as dressing changes, suctioning, and oxygen administration Teaching parents about medication administration Teaching parents about safety issues such as car seat use, and positioning the infant on his or her back during sleep Encouraging parents to learn infant CPR Teaching parents about basic newborn care Educating parents on what to expect after discharge, such as sleep patterns, feeding, infant behavior, and developmental milestones Discussing follow-up care such as physician's visits, immunization schedules, and appointments for developmental care
Assessment signs of persistent pulmonary HTN of the newborn?
Term/near-term Low apgar Symptoms within 12 hours of birth Hypoxia/asphyxia during birth Neonate depressed at birth, slow to breathe, difficulty with admin. of ventilation tachypnea Chest retractions, grunting Low PaO2 w/ high O2 admin Cyanosis hypotension heart murmur pulmonary disorders as possible complications EKG shows pulmonary HTN and enlarged right side of heart CHF hypoglycemia hypocalcemia metabolic acidosis possible kidney damage —> decreased urine output, proteinuria, hematuria liver damage —> blood clotting problems hematological problems (hemorrhage, DIC, thrombocytopenia) Long term: -Hearing loss -neuro deficits -chronic lung disease -death
What should the care of a newborn infant whose mother has had untreated syphilis since the second trimester of pregnancy include?
Testing for congenital syphilis (may not have signs/symptoms)
The parents of a newborn who is undergoing phototherapy ask the nurse why their baby's eyes are covered with eye patches. Which information is important for the nurse to remember before responding?
They prevent injury to the conjunctiva and retina
Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?
Verifying oxygen saturation frequently to adjust flow on the basis of need
A nurse in the neonatal intensive care unit (NICU) is assessing new parents for behaviors that might indicate difficulty with bonding. The nurse determines that support may be helpful when she observes the parents doing what?
Visiting other babies in the NICU
A newborn with acquired herpes simplex virus infection is being discharged. Which facet of development should the nurse instruct the parents to monitor closely?
Visual clarity
Important for O2 administration in preterm neonate
Warm + humidify
The nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe?
Webbed neck, female sex organs, widely spaced nipples
Appropriate weight gain for preterm infant
Weight gain of 10 to 20 grams per kilogram per day indicates appropriate growth and caloric intake for a preterm neonate
if HR < 60 after providing positive pressure ventilation, what do you do?
admin chest compressions and epinephrine if necessary
Assessment for LGA
birth trauma r/t should dystocia or breech presentation poor feeding behavior hypoglycemia polycythemia with diabetic mothers hyperbilirubinemia 48-72 hours after delivery r/t polycythemia, decreased ECF, bruising/hemorrhaging from birth trauma
Main two factors that influence newborn outcomes
birth weight + gestational age
What is a subdural hemorrhage?
bleeding beneath dura and causes pressure on brain (may cause hydrocephalus and hypoxic-ischemic injury)
The most rapid anatomic and physiologic changes of this period occur in the _______ system, so the newborn's major problems are usually related to this system.
cardiopulmonary
Consequences of intrauterine hypoxia
cellular damage in the CNS growth restriction of the fetus (IUGR, SGA) meconium passage and aspiration cognitive dysfunction cerebral palsy
Assessment findings for BPD
chest retractions wheezing/rales/rhonchi hypoxia respiratory acidosis bronchospasms difficult weaning from ventilator X-rays will show cardiomegaly, lung hyperinflation, infiltrates edema, weight gain, decreased urinary output (retention of fluids)
Methods of heat loss
conduction, convection, evaporation, radiation
Why should the neonate's environment be humidified?
decrease water loss that can occur through the neonate's immature skin, known as transepidermal water loss (TEWL)
What is cold stress?
excessive heat loss resulting in the use of compensatory mechanisms to maintain core body temp
Low birth weight puts premature infant at risk for which electrolyte imbalances?
hyperkalemia, hypo/hypernatremia
Complications of phototherapy
hyperthermia, lethargy, rash, abdominal distention, bronze baby syndrome, thrombocytopenia, eye damage, loose stools, dehydration, hypocalcemia
Causes of polycythemia
may be caused by delayed cord clamping (get too much blood from placenta) may be caused by twin-to-twin transfusion syndrome or chronic intrauterine hypoxia (baby produces more RBCs) generally present with other chromosomal abnormalities, other endocrine disorders, or high altitude births (lower O2)
signs of intracerebellar hemorrhage?
may have apnea, bradycardia, bloody CSF within 2-3 days
Vertical transmission of infection
mom to baby
Cascade of complications w/ hemolytic disease of the newborn?
mom's Rh antibodies can migrate into infant's circulation and cause hemolysis of baby's RBCs, causing anemia and reducing the O2 delivery in the baby's body, fetal heart will try to compensate and can lead to fetal cardiac failure, and as the RBCs breakdown, bilirubin is excessively released and this is toxic to neurological tissue and can cause kernicterus/brain damage, can also cause enlargement of liver/spleen that try to produce more RBCs, liver function is reduced, albumin levels drop and can cause edema, can even cause intrauterine death, baby may need blood transfusions after birth but it's hard to UNDO this damage
Nursing actions with hyperbilirubinemia
monitor for kernicterus (can cause neurological sequalae) and monitoring for/preventing injury from phototherapy, assess degree of jaundice w/ transcutaneous meter, obtain serum bilirubin levels, ensure adequate hydration for excretion Assess degree of jaundice every shift by blanching and looking for a yellowing and ensure adequate hydration (feed q 2-3 hours)
What is periventricular leukomalacia?
necrosis of periventricular white matter, resulting from ischemia causes a range of CNS manifestations
Postmaturity
neonate > 41 weeks
Horizontal transmission of infection
nosocomial infections
Causes for physiologic jaundice
occurs due to shortened lifespan of RBCs, decreased hydration, and immature liver
What is/causes patent ductus arteriosus?
occurs when the ductus arteriosus remains open after birth (typically due to prematurity and LBW)
Methods of heat production in newborn
peripheral vasoconstriction (reduced O2 available to tissues) - adults = shivering - infants = flexion, movement increased muscle flexion and activity (may be impossible for premature infants - mostly extended so they experience rapid heat loss) brown fat metabolism **most utilized by newborn - role of norepinephrine - increased risk for hyperbilirubinemia and kernicterus - more premature = less brown fat stored
Risks for periventricular/intraventricular hemorrhage
preterm, RDS, complications with ventilation, amniotic fluid infection, perinatal asphyxia, increased arterial pressure, low 5-minute Apgar score, maternal general anesthesia, low birth weight, alteration of BP, acidosis, hypercarbia, low Hct, pneumothorax
Risk factors for neonatal hypoglycemia
preterm, SGA, LGA, born to diabetic mother
Nursing actions for cold stress
prevention: keep eye on baby's temp, do not bathe/put near drafty vent until stable temp > 97.6 If occurs, place baby in warmer that is 1-1.5 degrees warmer than baby's temp (warm slowly, increase by 1 degree/hr), keep baby naked, monitor temp 15-30 mins while warming, skin thermometer measures continuously, warm IV fluids prior to administration
What is asphyxia in the neonate?
reduction of O2 delivery and accumulation of CO2 due to cessation of blood supply to the fetus around the time of birth (EMERGENCY) - no spontaneous breathing or breathing movement after birth - usually caused by perinatal hypoxia
What is persistent pulmonary HTN of the newborn?
results when the normal vasodilation and relaxation of the pulmonary vascular bed do not occur. This leads to elevated pulmonary vascular resistance, right ventricular hypertension, and right-to-left shunting of blood through the foramen ovale and ductus arteriosus
Nursing Actions for SGA
review records for risk gestational age assessment assess resp. distress assess gross anomalies assess skin for meconium staining maintain NTE decrease risk of hypoglycemia monitor hypocalcemia daily weights monitor VS monitor feeding intolerance obtain labs educate parents on keeping baby warm and providing freq. feedings
Cold stress in the term newborn can cause pulmonary vasoconstriction leading to ____
right to left shunting and hypoxemia
Long term complications of CNS injuries
seizures neurological deficits developmental disability motor deficits visual impairments death
Symptoms of subdural hemorrhage
seizures, increased loss of consciousness, asymmetric motor functioning, bulging fontanel, lethargy, facial paralysis
The nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal?
tachypnea, exaggerated moro reflex, prolonged high pitched cry, restlessness and excessive activity
Nursing actions for substance abuse moms
■ Review maternal history, including risk factors of substance use and history of current or past substance use. ■ Assess the neonate, including gestational age. ■ Assess for congenital anomalies and physical and behavioral signs of withdrawal/neonatal abstinence syndrome ■ Monitor vital signs. ■ Obtain toxicology screening as per order. (A clean catch urine or meconium sample may be ordered) ■ Use a scoring tool to assess for signs of withdrawal on neonates who are at high risk for neonatal abstinence syndrome (Notify the physician if the score is outside of what is considered normal; The decision to treat with medication is based on the infant's score.) ■ Care for neonates experiencing neonatal abstinence syndrome: Assess feedings and daily weights: - Increased activity, decreased sleep, irritability, loose stools, vomiting, and poor feeding behavior may all result in increased caloric needs. Provide frequent and small feedings: - A higher calorie formula (22-24 cal/oz.) can be used to support increased caloric needs - Allow the neonate to rest during feedings - Position the neonate upright during feedings - Utilize nipples that have a slower flow if the infant has a strong, frantic suck Provide a pacifier to the neonate Bathe the baby in warm water to treat increased tone and irritability Swaddle neonate with arms close to the body Provide a quiet environment, with lights dimmed, and minimize stimuli Be sensitive to infant cues that indicate stress; minimize stress-inducing activities Rock the neonate gently Care for the mother of a neonate with neonatal abstinence syndrome: ■ Provide nonjudgmental, honest, supportive care. ■ Teach what to expect in regard to the neonate's behavior. Educate about strategies that will provide comfort to her infant during withdrawal. ■ Teach her how to feed her infant. ■ Observe maternal-newborn interactions and involve the mother in the care of her newborn ■ Neonates who have been exposed to substances during the prenatal period often exhibit behaviors that interfere with the maternal-newborn relationship, such as irritability, resistance to being comforted, arching while being held, altered sleep states, poor feeding behavior, easily agitated when stimulated, and difficult transitions from one state to another. ■ Characteristics of mothers with a history of substance abuse that may impair the maternalnewborn relationship include lack of sensitivity to infant cues, lack of emotional stability, lack of communication with the infant, and inconsistent/ unavailable caregiving. ■ Document all assessments and observations in the medical record per agency protocol
