ATI OB Book Ch 27 Newborn Complications

Lab tests for hypoglycemia

2 consecutive plasma glucose levels <40 mg/dL in term newborn and <25 in preterm newborn.

Hematocrit indicating hypoxia in newborn

> 65%.

Physiologic jaundice

Benign. Occurs from breakdown of fetal RBCs and liver immaturity. Jaundice occurs after 24 hours of age. There are no other manifestations.

Complications of respiratory distress syndrome

Complications are related to oxygen therapy and mechanical ventilation: Pneumothorax. Pneumomediastinum. Retinopathy of prematurity. ROP not common anymore. Used to give too much O2, now know better. Bronchopulmonary dysplasia. Infection. Intraventricular hemorrhage.

Discharge instructions for neonatal infection

Educate parents: Adequate hand washing. Rest for newborn. Decreased physical stimulation. Clean bottles and nipples for each feeding. Discard unused formula.

Hyperbilirubinemia

Elevation of serum bilirubin levels resulting in jaundice. Can lead to kernicterus. Can result in hypoxia, hypoglycemia, hypothermia, and metabolic acidosis, and may increase brain damage.

How Finnigan scale rates GI disturbances

Excessive sucking. Poor feeding. Regurgitation versus vomiting. Loose versus water stools.

Injury suggested by facial flattening, unresponsiveness to grimace, eyes unable to close

Facial nerve palsy.

Treating opioid dependent mother during pregnancy

Goal is maintenance, not abstinence. Methadone with starting dose of 10-20 mg daily. If on buprophenone and naloxone (Suboxone), switch to buprophenone (Subutex) alone. Methadone is standard of care, but bupreophenone shows promise.

Nursing care for hypoglycemia

Heel stick for glucose monitoring. Frequent oral/gavage feeding or continuous parenteral nutrition. Monitor baby's glucose per protocol. IV if baby unable to feed orally.

Bronchopulmonary dysplasia

Lungs become stiff and noncompliant. Newborn requires mechanical ventilation and O2 and may be difficult to wean from vent.

Hydrops fetalis

Massive edema of fetus caused by hyperbilirubinemia.

Risk factors for hypoglycemia

Maternal diabetes mellitus. Preterm infant. LGA or SGA. Stress at birth. COLD STRESS because baby uses up energy to keep warm. Maternal epidural anethesia.******

Goals of care for preterm newborn

Meeting growth and development needs. Anticipating and managing complications.

Medications for neonatal substance withdrawal

Most often give morphine. If CNS irritability is really bad, will be put on phenobarbital. Extended stay in hospital. Watch Finnigan score and start medications as it reaches certain level, then wean according to Finnigan scale. Phenobarbital (Solfoton) is anticonvulsant to decreases CNS irritability and control seizures for newborns with alcohol or opiate addiction.

Large for gestational age newborn, macrosomia

Neonate who weighs about 90th percentile or more than 4000 g (8 lb, 12 oz). May be preterm, term, or postterm. Not necessarily postmature.

Risk factors for neonatal infections

PROM. TORCH infections. Chorioamnionitis. Premature birth or low birth weight. Maternal substance use. Maternal UTI. Meconium. HIV through placenta or breast milk.

Nursing assessment for neonatal substance withdrawal

Perform neonatal abstinence scoring. Assess reflexes. Monitor ability to feed and digest. Monitor fluid, electrolytes, skin turgor, mucous membranes, fontanels, I&O. Observe behavior.

Hypoglycemia

Serum glucose level of <40 mg/dL. However, in preterm newborn in first 3 days of life, hypoglycemia is <25 mg/dL. Routine assessment of newborns, especially SGA or LGA, should include monitoring for hypoglycemia.

Injury suggested by localized discoloration, ecchymosis, petechia, edema

Soft tissue injury.

Leading risk factor for large for gestational age newborn

Uncontrolled hyperglycemia, which stimulates continued insulin production by fetus.

Periodic breathing

5- to 10-second respiratory pauses followed by 10- to 15-second compensatory respirations.

Fetal alcohol syndrome (FAS)

Alcohol-related neurodevelopmental disorder. Caused by chronic or periodic intake of alcohol during pregnancy. Alcohol considered teratogenic. Newborns with FAS are at risk for specific congenital physical defects as well as long term complications: Feeding and sleep problems. CNS dysfunction. Behavioral difficulties. Language abnormalities. Future substance use. Delayed growth and development. Poor maternal newborn bonding.

Nursing care for neonatal infection

Assess infection risks. Review record. Monitor for signs of opportunistic infections. Monitor vital signs, I&O, daily weight, fluid and electrolyte status. Monitor visitors for infection. Obtain specimens. Administer IV therapy as ordered. Medications as prescribed. Broad spectrum antibiotic prior to culture results. Standard precautions. Respiratory support as needed. Monitor IV site for infection.

Post-term infant

Baby born after completion of 42 weeks of gestation. Postmaturity: Post date plus symptoms of placental insufficiency. Postmature infants have increased risk for aspirating meconium. Complication of meconium aspiration is persistent pulmonary hypertension. Newborn can be SGA or LGA depending on how well placenta functions in last weeks. Can be associated with either dysmaturity or continued growth in utero.

Assessment of preterm newborn

Ballard assessment (assess physical and neurologic status) showing gestational age <37 weeks. Respiratory effort or distress, periodic breathing, apnea. Tachycardia. Newborn with low birth weight. Minimal subcutaneous fat. Newborn's head is large compared to body (contrast with SGA). Fontanels small. Wrinkled features, lanugo, few or no creases on feet. Look like wrinkled old man. Skull and rib cage feel soft. Eyes closed if born at 22-24 weeks. Unable to coordinate suck/swallow and has weak or absent gag, suck, and cough reflex. Hypotonic muscles, decreased activity, weak cry more than 24 hours. Lethargic. Observe for infection or dehydration or overhydration.

Medications for preterm newborn

Betamethasone (Celestone) for 24 hours to promote fetal lung maturity.

Kernicterus

Bilirubin encephalopathy. Neurological disorder resulting from bilirubin depositing in brain cells. Results from untreated hyperbilirubinemia. Bilirubin levels may be >25 mg/dL. Survivors may develop cerebral palsy, epilepsy, mental retardation, learning disorders, perceptual-motor disabilities.

Parameters for pathologic jaundice in term newborn

Bilirubin increases at greater than 0.5 mg/dL/h or peaks at greater than 13 mg/dL or is associated with anemia and hepatosplenomegaly.

Complications of large for gestational age

Birth injuries: Shoulder dystocia, clavicle fracture, Erb-Duchenne paralysis, intracranial hemorrhage, CNS injury. Cesarean birth. Asphyxia. Hypoglycemia. Polycythemia. Secondary to hyperglycemia: Congenital defects including heart defects, tracheoesophageal fistula, CNS anomalies.

Small for gestational age

Birth weight is at or below 10th percentile and has intrauterine growth restriction (IUGR).

Klumpke's palsy

Brachial plexus palsy affecting muscles of forearm and hand. Lower brachial plexus injury.

Lab tests for neonatal infection

CBC. Chemistries for electrolyte imbalance. Blood, urine, and CSF culture and sensitivity. Blood culture if positive is usually polymicrobial.

Opiate withdrawal syndrome

Can last 2-3 weeks. Rapid changes in mood, hypersensitivity to noise and external stimuli, dehydration, poor weight gain.

Priority in treating preterm newborns

Cardiac and respiratory support. Thermoregulation. Usually NICU care until feeding orally, maintaining temperature, and weight 2 kg (4.4 lb).

Retinopathy of immaturity

Caused by abnormal growth of retinal blood vessels, a complication associated with O2 administration. Can cause mild to severe eye and vision problems.

Injury suggested by limited motion of arm, crepitus, absence of Moro on affected side

Clavicle fracture.

Risk factors for small for gestational age newborn

Congenital or chromosomal abnormalities. Maternal infection, disease or malnutrition. Gestational hypertension or diabetes. Maternal smoking, drug or alcohol use. Multiple gestation. Placental factors (small placenta, previa, decreased perfusion). Fetal congenital infections like rubella, toxoplasmosis.

Nursing care for neonatal substance withdrawal

Decrease environmental stimuli. Cluster care. Swaddle to reduce self stimulation and to protect from abrasions. Monitor and maintain fluids and electrolytes. Frequent and small feedings of high-calorie formula. May need gavage feedings. Elevate head following feedings and burp to reduce vomiting, aspiration. Have suction available. Find appropriate nipple to compensate for poor suck reflex. For cocaine withdrawal, avoid eye contact, use vertical rocking and pacifier. Prevent infection. Lactation consult to determine if breastfeeding OK. It is OK with methadone. Social service consult, DCF involvement. Refer mom to treatment. SIDS education, especially for moms on methadone.

Signs of increased intracranial pressure

Dilated pupils, vomiting, bulging fontanels, high-pitched cry.

Injury suggested by flaccid arm w/elbow extended and hand rotated inward, absence of Moro, loss of sensation on lateral arm, and intact grasp

Erb's palsy.

How Finnigan scale rates CNS disturbances

Excessive versus continuous high-pitched cry. Sleeps <1, <2, or <3 hours after feeding. Hyperactive versus harkedly hyperactive Moro. Mild versus moderate-sever tremors. Increased muscle tone. Excoriation. Myoclonic jerks. Generalized convulsions.

Typical morphologic features of fetal alcohol syndrome

Eyes: Short palpebral fissures. Epicanthal folds. Strabismus. Ptosis. Nose: Short nose. Low nasal bridge. Ears: Minor ear anomalies. Deafness. Mouth: Thin upper lip. Poor suck. Small teeth. Cleft lip/palate. Flat midface. Indistinct philtrum. Micrognathia. Abnormal palmar creases. Irregular hair. Heart defects like ASD, VSD, tetralogy, PDA.

Risk factors for birth injury

Fetal macrosomia. Abnormal/difficult presentations. Erb's palsy with shoulder dystocia. Prolonged/precipitous labor. CPD. Multifetal gestation. Congenital abnormalities. Internal monitoring with injury to scalp. Forceps/vacuum extraction. External version. Cesarean birth with possible scalpel laceration.

Usual progression of jaundice in newborn

First appears in head, especially sclera and mucous membranes, and progresses downward. That is why TCB is done on forehead.

Methadone withdrawal syndrome

Increased incidence of seizures, sleep disturbances, higher birth weights, higher risk of SIDS.

Necrotizing enterocolitis

Inflammatory disease of GI mucosa due to ischemia. Results in necrosis and perforation of bowel. May result in removal of most or part of small intestine leading to short gut syndrome.

Diagnostic procedures for birth injury

Injuries diagnosed with CT scan, xray, neurological exam.

Injury suggested by flaccid muscle tone

Joint dislocation and separation, plexus injury, or long bone fracture.

Lab tests and diagnostic procedures for small for gestational age newborn

Lab tests: Blood glucose for hypoglycemia, CBC (reveals polycythemia from fetal hypoxia and intrauterine stress), ABGs. Diagnostics: Chest x-ray to rule out meconium aspiration.

Lab tests and diagnostic procedures for large for gestational age newborn

Labs: Blood glucose for hypoglycemia, ABGs (for hypoxia from placental insufficiency), CBC (polycythemia from hypoxia), hyperbilirubinemia (breakdown of RBCs with polycythemia), hypocalcemia (due to long and difficult birth). Diagnostics: Chest x-ray for meconium aspiration.

Lab tests and diagnostic procedures for post-term infant

Labs: Blood glucose for hypoglycemia. CBC for polycythemia. Hct may also be up from dehydration. ABGs for chronic hypoxia from placental insufficiency. Diagnostics: Chest x-ray to rule out meconium aspiration.

Lab tests and diagnostic procedures for respiratory distress syndrome

Labs: Blood, urine, CSF cultures. Blood glucose. Serum calcium. Diagnostics: ABG showing hypercapnia and respiratory or mixed acidosis. CXR.

Lab tests and diagnostic procedures for preterm newborn

Labs: CBC with decreased H&H from slow RBC production, UA (specific gravity), PT/PTT increased, blood glucose, calcium, bilirubin, ABGs. Diagnostics: Chest x-ray, head ultrasound, echocardiogram, eye exam.

Lab tests and diagnostics for neonatal substance withdrawal

Labs: CBC, blood glucose, calcium, magnesium, thyroid function tests, drug screen (urine, meconium, or hair analysis). Diagnostics: Chest x-ray for FAS to rule out congenital heart defects.

Injury suggested by weak or hoarse cry

Laryngeal nerve palsy.

Heroin withdrawal syndrome

Low birth weight and SGA, decreased Moro (rather than increased), hypothermia or hyperthermia.

Risk factors for prematurity

Maternal gestational hypertension. Shortly spaced pregnancies. Adolescent pregnancy. No prenatal care. Maternal substance use. History of preterm delivery. Uterine abnormalities. Cervical incompetence. PROM, PPROM, premature labor. Placenta previa.

Neonatal substance withdrawal

Maternal substance use during pregnancy (alcohol/drugs) can cause anomalies, neurobehavioral changes, and evidence of withdrawal. Changes depend on specific drug used, dose, timing, and length of drug exposure. Substance withdrawal occurs when mother uses drugs that have addictive properties during her pregnancy, including alcohol, tobacco, prescription drugs. Babies have especially hard time withdrawing from methadone. Also difficult because it is newborn with behavioral problems born to mother who already has demonstrated poor coping skills.

Neonatal infection, sepsis

May be contracted by newborn before, during or after delivery. Presence of micro-organisms or toxins in blood or tissues in first month of life. Because of limited immunity and inability to localize infections, infection may spread rapidly to bloodstream. Manifestations are subtle.

Nursing care for post-term infant

Monitor vital signs. Maintain thermoregulation in isolette. IV fluids prn. Exchange transfusion if hematocrit is high. Mechanical ventilation or O2 as prescribed. Early feedings to prevent hypoglycemia. Identify and treat birth injuries. Don't put lotions on dry skin: Dyes and perfumes not good.

List of newborn complications

Neonatal substance withdrawal. Hypoglycemia. Respiratory distress syndrome (RDS), asphyxia, meconium aspiration. Preterm newborn. Small for gestational age newborn (SGA). Large for gestational age newborn (LGA), macrosomia. Posterm infant. Neonatal infection, sepsis (sepsis neonatorum). Birth trauma, injury. Hyperbilirubinemia. Congenital anomalies.

Preterm newborn

Newborn born after 20 weeks of gestation and before 37 weeks gestation. May occur once cervix dilates to 4 cm. Preterm newborn at risk for a variety of complications due to immature organ systems. There is a decreased risk of complications when newborn closer to 40 weeks of gestation.

Respiratory distress syndrome

Occurs due to surfactant deficiency in lungs. Characterized by poor gas exchange and ventilatory failure. Surfactant is phospholipid that assists in alveoli expansion and keeps alveoli from collapsing and allows gas exchange to occur. Atelectasis increases work of breathing. Respiratory acidosis and hypoxemia can develop. Maturity of lungs and adequacy of surfactant cannot be assessed by birth weight alone.

Common complications of small for gestational age newborn

Perinatal asphyxia. Meconium aspiration. Hypoglycemia. Polycythemia. Temperature instability.

Persistent pulmonary hypertension (PPH)

Persistent fetal circulation. May result from meconium aspiration. Ductus arteriosus (connecting pulmonary artery and aorta) and foramen ovale (shunt from right to left atrium) remain open.

2 types of jaundice

Physiologic. Pathologic.

Continued growth of post-term fetus in utero

Placenta continues to function effectively. Fetus continues to grow and is LGA at birth, which can lead to difficult delivery, CPD, birth trauma, perinatal asphyxia, hypoglycemia, seizures, cold stress.

Dysmaturity in post-term infant

Placenta functions effectively for only 40 weeks. Placental degeneration and uteroplacental insufficiency result in fetal hypoxia and fetal distress in utero. Response is polycythemia, meconium aspiration, respiratory problems. Perinatal mortality is high when placenta fails to meet increased oxygen demands of fetus during labor.

Signs and symptoms of hypoglycemia

Poor feeding. Jitteriness, tremors. Hypothermia. Diaphoresis. Weak shrill cry. Lethargy, decreased muscle tone. Seizures, coma. Irregular respirations, apnea. Cyanosis. Note: If only see decreased temperature and jitteriness, think hypoglycemia and check glucose.******

Risk factors for large for gestational age newborn

Post-term babies. Maternal gestational diabetes. Fetal cardiovascular disorder of transposition of great vessels. Genetic factors. Maternal obesity. Multiparous mother.

Tobacco withdrawal syndrome

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

Nursing care for large for gestational age newborn

Prepare for vacuum assisted delivery or cesarean. Prepare to place in McRoberts' position (lithotomy with knees flexed to chest to widen pelvic outlet) for shoulder dystocia. Early and frequent heel sticks for blood glucose. Early feeding or IV therapy to prevent hypoglycemia. Thermoregulation with isolette. Surfactant by endotracheal tube if needed. Identify and treat birth injuries.

Marijuana withdrawal syndrome

Preterm birth, meconium staining.

Risk factors for respiratory distress syndrome

Preterm gestation. Perinatal asphyxia (meconium, cord prolapse, nuchal cord). Maternal diabetes mellitus. PROM. Maternal use of barbituates or narcotics close to birth. Maternal hypotension. Cesarean birth without labor. Hydrops fetalis. Third trimester bleeding.

Amphetamine withdrawal syndrome

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

Routine prophylaxis for neonatal infections

Prevention starts perinatally with maternal screening for infections, prophylactic interventions, and sterile technique during delivery. Antibiotic treatment of eyes and appropriate umbilical cord care.

Complications preterm newborn is at risk for

RDS due to decreased surfactant in aveoli (regardless of birth weight). Bronchopulmonary dysplasia (BPD). Aspiration due to lack of intact gag reflex or ability to effectively suck and swallow. Apnea of prematurity from immature neurological and chemical mechanisms. Intraventricular hemorrhage (IVH): Bleeding in or around ventricles of brain. Retinopathy of prematurity (ROP). Patent ductus arteriosus (PDA) when ductus arteriosus reopens after birth due to neonatal hypoxia. Necrotizing enterocolitis (NEC). Infection. Hyperbilirubinemia. Anemia. Hypoglycemia. Delayed growth and development.

Nursing care of preterm newborns

Rapid initial assessment. Resuscitation prn. Vital signs. Observe eating, digesting Must have intact gag, suck, swallow to feed orally. Monitor I&O and daily weight. Observe for bleeding from GI tract and puncture sites. Thermoregulation with radiant heat warmer. Respiratory support measures: Surfactant, O2 and vent if needed. Parenteral or enteral nutrition by IV or gavage. Facilitate nonnutritive sucking w/pacifier during gavage feeding. Minimize stimulation. Cluster care. Touch lightly. Dim light. Low noise. Position in neutral flexion with extremities close to body to conserve body heat. If monitored, prone and sidelying preferred. Protect from infection. Hand hygiene. Gowning. No shared equipment. Meds as ordered.

Pathologic jaundice

Result of underlying disease. Occurs prior to 24 hours of age and/or persists after day 7. Usually caused by blood group incompatibility or infection. May be result of RBC disorders. Requires intervention.

Nursing care for birth injury

Review maternal history and Apgar for predisposing factors. Head to toe assessments. Vital signs, temperature. Promote parent-newborn interaction. Administer treatment as prescribed. Education for parents about injury and care.

Finnigan score

Scale for rating neonatal abstinence syndrome by CNS disturbances; metabolic, vasomotor, and respiratory disturbances; and GI disturbances. Institutional protocols determine at what score baby is medicated.

Possible consequences of untreated hypoglycemia

Seizures, brain damage, and/or death.

Types of birth trauma or injury

Skull fracture (depressed, linear). Scalp (caput succedaneum). Intracranial (epidural or subdural hematoma, cerebral contusion). Spinal cord (cord transection or injury, vertebral artery injury). Plexus (brachial plexus injury, Klumpke's palsy). Cranial and peripheral nerve (radial nerve palsy, diaphragmatic paralysis).

Frequent causative organisms of neonatal infection

Staphylococcus aureus, S. epidermidis, Escherichia coli, Haemophilus influenzae, and Group B strep.

Injury suggested by irritability/seizures within 72 hours, decreased LOC

Subarachnoid hemorrhage.

Nursing care for respiratory distress syndrome

Suction NB mouth & nose prn Monitor VS, maintain thermoregulation Ventilatory support/adequate oxygenation Decrease stimuli Meds: Beractant (surfactant)—restores surfactant and improves respiratory compliance Increased lung maturity in utero if: increased gestational age, intrauterine stress, exogenous steroid use and ruptured membranes

Nursing care for small for gestational age newborn

Support respiratory efforts and suction as needed. Neutral thermal environment (isolette or radiant warmer). Initiate early feedings, more frequent feedings. Parenteral nutrition if needed. Adequate hydration. Conserve newborn's energy level. Prevent skin breakdown. Protect from infection. Support family. Anticipate home care needs. "Feeders and growers": Stay in hospital just to feed okay and grow to OK size to send home.

How Finnigan scale rates metabolic, vasomotor, respiratory disturbances

Sweating. Fever <101 versus >101. Frequent yawning. Mottling. Nasal stuffiness. Sneezing. Nasal flaring. Respiratory rate >60 versus >60 with retractions.

Signs and symptoms of respiratory distress syndrome

Tachypnea, nasal flaring, expiratory grunting, retractions, labored breathing with prolonged expiration, fine crackles on auscultation, cyanosis, unresponsiveness, flaccidity, apnea, decreased breath sounds. Grunting may sound like cooing. Retractions usually seen between ribs rather than at sternum.

Assessment for neonatal infection

Temperature instability. Have to monitor newborn closely. Might result in low temperature, not fever. Have to watch trends and look at big picture. Consider infection if low temperature for no good reason. Drainage from eyes, umbilical stump. Poor feeding, poor weight gain, abdominal distention, high residual if gavage, vomiting, diarrhea. Respiratory distress, decreased O2 sats. Color changes: Pallor, jaundice, petechiae. Tachycardia, bradycardia, tachypnea, hypotension. Seizure activity, irritability, poor muscle tone, lethargy.

Erb's palsy

Upper brachial plexus injury.

Signs of overhydration

Urine output greater than 3 mL/kg/h, urine specific gravity less than 1.001, edema, increased weight gain, crackles, intake greater than output.

Signs of dehydration

Urine output less than 1 mL/kg/h, urine specific gravity greater than 1.015, weight loss, dry mucous membranes, poor skin turgor, depressed fontanels.

Monitoring for abstinence syndrome

Use scoring system that rates the following: CNS: Increased wakefulness, cry, irritability, tremors, increased reflexes and muscle tone, excoriations on face and knees, seizures. Metabolic, respiratory, vasomotor symptoms: Nasal congestion with flaring, yawning, skin mottling, tachypnea, sweating, temperature >99. GI: Poor feeding, regurgitation, diarrhea, uncoordinated sucking. (Diarrhea adds to irritability because skin is raw, red, and painful.)

Medications for neonatal infection

Usually combination of ampicillin with aminoglycoside or third-generation cephalosporin like Rocephin for suspected sepsis. Ampicillin (Principen). Broad-spectrum bactericidal antibiotic. Gentamycin sulfate (Garamycin). Bactericidal aminoglycoside antibiotic. Need peak and trough levels.

Risk factors for post-term infant

Usually, cause is unknown. Higher incidence in first pregnancies and women who have had previous post-term infants.

Assessment of post-term infant

Wasted appearance, loose skin, loss of some subcutaneous fat. Wasted because placenta is failing and have to use own resources. Peeling, cracked and dry skin (desquamation). From decreased protection of vernix and amniotic fluid. Long, thin body. Meconium staining of fingernails and umbilical cord. Light green color to cord and sac because of meconium staining. May have long hair and nails. Alertness may be similar to 2 week old infant. Difficulty establishing respirations if meconium aspiration. Hypoglycemia due to insufficient glycogen stores. Findings of cold stress. Macrosomia.

Assessment of small for gestational age newborn

Weight <10th percentile. Normal skull, but reduced body dimensions. Unlike premie, head does not look big for body. Wide skull sutures from inadequate bone growth. Sparse hair. Dry loose skin. Decreased subcutaneous fat. Decreased muscle mass, especially cheeks and buttocks. Thin, dry, yellow, dull umbilical cord rather than gray, glistening, moist. Drawn, not rounded abdomen. Respiratory distress, hypoxia, may be meconium aspiration. Wide eyed and alert due to prolonged fetal hypoxia. Makes baby look healthier than he really might be. Hypotonia. Hypoglycemia. Acrocyanosis.

Assessment of large for gestational age newborn

Weight >90th percentile or 4000 grams. Gestational age assessment is important because big baby may be preterm and LGA. Plump full face (cushingoid) from increased subcutaneous fat. May see evidence of respiratory distress, hypoxia. Birth trauma. Hypotonic muscles, hypoactive, sluggish. Tremors from hypocalcemia. Hypoglycemia. Respiratory distress from immature lungs or meconium. Findings of increased intracranial pressure.