Chapter 51: Neonatal and Newborn

FDA has approved the use of the *synthetic surfactant drugs* NOT IN DRUG GUIDE

*beractant, calfactant, and poractant alfa*

Respiratory Distress Syndrome (RDS) can occur bc of

*immature lung development/breathing control and decreased airway muscle tone/surfactant level*

Nursing Diagnosis for Surfactants

-*Gas Exchange, Impaired related to inadequate lung surfactant secondary to fetal immaturity* -Knowledge, Deficient (parents) related to treatment needs of the infant

Nursing Diagnosis for Drugs Administered to Full-Term, Healthy Neonates

-*Injury, Risk for neonatal* -Knowledge, Deficient parental related to immunization misinformation

Nursing Interventions for Surfactants

-*Maintain a patent airway* -*Continuously monitor vital signs before, during, and after surfactant therapy* -Ventilation-perfusion matching can occur rapidly after administration, anticipate need to alter ventilator settings -*Maintain adequate respiratory status* -*Have a multidisciplinary team at the bedside* -*Monitor ABGs and obtain a chest radiography study* -Prepare and administer drug according to the manufacturer's drug insert -Do not perform ET suction immediately after administration of surfactant unless signs of airway obstruction are present -*Position and reposition the infant as needed for equal distribution of surfactant throughout the lungs* -Support and educate parents -Acknowledge the parents' concerns regarding the well-being of the newborn

Assessment with Surfactants

-*Obtain informed consent* -Separate consents are needed for multifetal births -*Vital signs, physical exam, and monitor arterial blood gases (ABGs)*

Nursing Interventions for Drugs Administered to Full-Term, Healthy Neonates

-*Obtain parental consents for immunizations* -Do not delay skin-to-skin contact bt mother/infant while preparing medications and immunizations. Skin-to-skin contact in the first hour of birth prevents hypothermia and promotes breastfeeding -*Wear gloves for administration* -If the mother is HBsAg positive, prepare to administer HBIG to the infant -Prepare and administer drugs and immunizations according to the manufacturer's instructions while the infant maintains contact with the mother's skin -*Administer erythromycin ophthalmic ointment before administration of phytonadione and hepatitis B injections* -The infant may cry after injections, making administration of ophthalmic ointment more difficult -*Monitor for any reactions*, such as redness and swelling in and around the eye from the eye ointment or redness, swelling, or ecchymosis at injection sites. Monitor for any respiratory distress (e.g., grunting, apnea, nasal flaring) -Acknowledge parent concerns about immunizations -Provide printed literature on hepatitis B and other immunizations

Assessment of Drugs Administered to Full-Term, Healthy Neonates

-*Signs of distress such as cyanosis, bleeding, ecchymosis, apnea, fever, and hypotension* -*Mother's HB status* -Parents' knowledge of treatments (e.g., medications and immunizations) given to their newborn

Phytonadione

-*Synthetic vitamin K* -Fat-soluble vitamin to *prevent vitamin K deficiency bleeding (VKDB)* -Single-dose injection within 1 hr after birth into vastus lateralis -*Side effects: pain/edema at injection site* -*Allergic reactions: urticaria/rash reported* -With larger doses: *hyperbilirubinemia and jaundice resulting from competition for binding sites* -Anticoagulant antagonist for prevention of hemorrhagic disease of the newborn

Planning for Drugs Administered to Full-Term, Healthy Neonates

-*The neonate will experience minimal or no side effects from drugs routinely administered after delivery* -Parents will express understanding of medications and immunizations given to their newborn

Planning for Surfactants

-*oxygen requirement and respiratory effort will decrease* -need for mechanical ventilation will be quickly reduced -will experience no respiratory distress after surfactant administration

Recombinant hepatitis B

-3 dose series -Indicated for HBV prophylaxis -First injection is given within 12 hrs of birth, then at 1 mo. and 6 mo. of age into vastus lateralis -Can provide active immunity against HBV by stimulating immune system to produce antibodies against hep B (anti-hepatitis B antigen) -Can be given concurrently with HBIG -Adverse effects: mild, pain, tenderness, pruritus, erythema, swelling, induration at site -Protection usually occurs 1 mo. after third dose -Also protects against hep D since it only occurs in people infected with hep B

Erythromycin Ophthalmic Ointment

-Administered to eyes *within the first hour of birth* in lower conjunctival sacs -Given as *prophylaxis against eye infections* (ophthalmia neonatorum, gonococcal/chlamydial conjunctivitis) -*Side effects: chemical conjunctivitis (20% occurrence) manifesting as edema/inflammation that lasts 24-48 hrs* -may interfere with eye-to-eye contact w/ parents

Evaluation for Drugs Administered to Full-Term, Healthy Neonates

-Evaluate for newborn bleeding, particularly on days 2 and 3 after administration of phytonadione -Evaluate for drug hypersensitivity or side effects -Evaluate parents' understanding about medications administered to their newborn

Evaluation for Surfactants

-Evaluate preadministration breath sounds, ABGs, respiratory status, and ventilator pressure readings to compare with postadministration findings -Evaluate the effectiveness of teaching to parents

Hepatitis B immune globulin (HBIG)

-Given to infants born to mothers who are positive for Hepatitis B surface antigen (HBsAg) -Provides passive protection against HBV -*Adverse effects: pain, tenderness, erythema at injection site, hypotension, rash, anaphylaxis* -Given within 12 hrs after birth to vastus lateralis -Obtain consent from parents -initiate recombinant HB as a separate injection at different site

Patient Teaching for Drugs Administered to Full-Term, Healthy Neonates

-Instruct parents regarding the action, purpose, and side effects of medications and immunizations -Inform parents that any edema around the eyes usually disappears within 24 to 48 hours -Explain to parents the difference between HBIG and recombinant HB injections. -Instruct parents regarding childhood immunizations as recommended by current immunization schedules, and inform them when repeat doses should be given. Give parents written information regarding the infant's immunization record and vaccination schedule. Document administration of hepatitis B vaccine on the infant's immunization record -Instruct parents on the signs and symptoms of adverse effects and when to notify the nurse

Immature lungs have a lower than normal level of

-Surfactant -surfactant replacement used to minimize respiratory difficulties in preterm neonate -supplements amount of endogenous surfactant available to maintain distention of alveolar sacs

Patient Teaching for Surfactants

-What RDS is and how surfactant helps the neonate -Purpose of multiple monitoring devices to reduce unrealistic fears about the neonate's condition -Ensure informed consent for drug usage -Encourage parents to verbalize their understanding about risks associated with use of the drug

Synthetic Surfactant is necessary to

-decrease the surface tension of the *alveoli* (air sacs) to allow the lungs to fill with air and prevent the alveoli from deflating -a lipoprotein

Calfactant

-doesn't require reconstitution -doesn't need to be warmed -calf-derived -*approved for prophylaxis(prevention) and rescue treatment* -divided in two equal amounts given over 20-30 breaths during the inspiratory phase with repositioning/monitoring in between each half

Beractant intratracheal suspension

-natural bovine lung extract* -contains phospholipids, neutral lipids, fatty acids, and surfactant-associated proteins -colfosceril palmitate, palmitic acid, and tripalmitin are added -does not require reconstitution -needs to be warmed to room temp prior to use -approved for *prophylaxis(prevention) and rescue treatment* -administered in 4 equal amounts followed by repositioning and ventilation every 20 secs after each quarter

Drugs Administered to Full-Term, Health Neonates

-newborns should receive eye care (erythromycin ophthalmic ointment), phytonadione, and immunizations for hep B. -antiinfective agent (chlorhexidine) applied to cord stump during first few hours after birth and for up to 1 week for at-risk newborns/newborns born in homes

Poractant alfa

-porcine-derived lung surfactant -*rescue treatment only* -should be slowly warmed to room temp -doesn't need reconstitution -divided into two equal amounts, give halfs to each main bronchus followed by repositioning/monitoring

perinatal transmission

-primarily transmits at the time of delivery

Surfactant treatment

-require patent endotracheal tube for administration -repositioning allows gravity to ensure even drug dispersion throughout lungs/alveolar space -crackles/moist breath sounds may be found after administration (Beractant) Complications: -hyperoxia (excessive oxygenation) -hypocarbia (decreased carbon dioxide) -transient endotracheal reflux obstructs ET tube and leads to oxygen desaturation, cyanosis, bradycardia, and apnea (suction before administering to decrease chance) Slow/halt dosing if: (1) becomes dusky colored, (2) becomes agitated, (3) experiences transient bradycardia, (4) has oxygen saturation increases of more than 95%, (5) experiences improved chest expansion, or (6) has arterial or transcutaneous CO2 levels below 30 mm Hg

A neonate whose mother is positive for the hepatitis B surface antigen (HBsAg) is admitted to the nursery. Which immunizations are appropriate for this neonate? (Select all that apply.) a. Hepatitis B immune globulin (HBIG) b. Recombinant hepatitis B (HB) c. Haemophilus influenzae type B d. Hepatitis A e. Phytonadione

A, B, E

The nurse is mentoring a new graduate who is preparing to administer the phytonadione injection to a newborn. Which muscle sites selected by the new graduate would indicate the need for further teaching? (Select all that apply.) a. Anterolateral thigh b. Gluteus maximus c. Rectus femoris d. Vastus lateralis e. Vastus medialis

A, D

medical history should be conducted with

AIDS, Group B streptococcal infection, viral hep B or C

The nurse is preparing to administer an ophthalmic drug to a newborn. Education for the parents includes which fact about the drug? a. Infants of mothers who test positive for syphilis receive this medication. b. Eye ointments are administered in the bottom of the eye from the inner to the outer eye. c. This drug will prevent congenital cataracts. d. Infants with a negative direct Coombs test receive this drug.

B

A patient asks the nurse why her baby is receiving a vitamin K injection. The nurse's best response is based on what knowledge? a. Vitamin K causes an increase in newborn platelets. b. A newborn's liver is too immature to produce vitamin K. c. A newborn lacks appropriate intestinal flora to synthesize vitamin K. d. Vitamin K is not produced in bone marrow until an infant is 8 days old.

C

It is mandatory to have maternal signed consent before administering which newborn drug? a. Erythromycin ophthalmic ointment b. Phytonadione c. Hepatitis B vaccine d. Betamethasone

C

A newborn is admitted to the nursery, and the nurse reviews the maternal history. It is important that the nurse assess the mother's status specific to which infectious process(es)? (Select all that apply.) a. Rubeola b. Hepatitis A c. Hepatitis B d. HIV/AIDS e. Group B Streptococcus

C, D, E

Immunizations

Hepatitis B immune globulin (HBIG) Recombinant hepatitis B -HBV infection may result in serious *long-term lover disease, cancer, and death* in adulthood -*Goal is to reduce virus carriers* and decreasing prevalence of HBV infection -HBV transmission occurs vertically, by perinatal transmission

Labor is determined to be preterm if it commences:

before 37 weeks of pregnancy

This chapter focuses on drugs commonly administered to the neonate which includes

late preterm newborns immediately after delivery

premature neonates are at risk for

respiratory distress, hypothermia, hypoglycemia, hyperbilirubinemia, and feeding difficulties

If no contraindications to stopping preterm labor

tocolytic therapy is administered to delay birth