Ch 26 PrepU: Nursing Care of a Family with a High-Risk Newborn

When discussing heat loss in newborns, placing a newborn on a cold scale would be an example of what type of heat loss?

A conduction heat loss results from direct contact with an object that is cooler.

An infant has a grade 3 intraventricular hemorrhage (IVH). For which potential complication should the nurse monitor this infant? 695

A grade 3 bleed causes enlargement of the ventricles. A long-term effect of hemorrhage may be the development of hydrocephalus. Encephalitis and meningitis are not complications of intraventricular hemorrhage (IVH). Intraparenchymal hemorrhage is seen in a grade 4 bleed.

Which result of a biophysical profile would indicate to the nurse that the fetus might tolerate labor poorly? Select all that apply.

A nonreactive NST, low amniotic fluid volume, and placental grade III are indicators of minimal reserves and that the fetus may not be able to tolerate the stress of labor. A positive stress test and poor fundal growth are also signs that the fetus is at risk, but they are not components of the biophysical profile.

The nurse examines a 26-week-old premature neonate. The skin temperature is lowered. What could be a consequence of the infant being cold?

A premature neonate has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.

A nurse is caring for a baby girl born at 34 weeks' gestation. Which feature should the nurse identify as those of a preterm newborn?

A preterm newborn has shiny heels and palms with few creases. The eyelids of the preterm newborn are edematous, and not paper-thin. The external genitalia in the preterm baby girl appear large with widely spaced labia, and not closely approximated. Vernix is scant in postterm newborns and is excessive in premature infants.

The nurse places a newborn experiencing respiratory difficulty under a radiant warmer to prevent which complication?

A radiant warmer is use to keep the infant warm. When an infant is cold, brown fat metabolism leads to acidosis, which would further complicate respiratory difficulties.

A client has given birth to a small-for-gestational-age (SGA) newborn. Which finding would the nurse expect to assess?

A small-for-gestational-age (SGA) newborn will typically have a head that is larger than the rest of his or her body. SGA newborns weigh below the 10th percentile on the intrauterine growth chart for gestational age. They have an angular and pinched face and not a rounded and flushed face. Round flushed face and protuberant abdomen are the characteristic features of large-for-gestational-age (LGA) newborns. Preterm newborns, and not SGA newborns, are covered with brown lanugo hair all over the body.

Which neonate will the nurse identify as most at risk of jaundice due to ABO incompatibility?

ABO incompatibility occurs when the pregnant client's anti-A or anti-B antibodies can cross to fetal/neonatal circulation at the time of birth and hemolysis of red blood cells may occur. This hemolysis results in the release of bilirubin in the blood. This is more common in term neonates than preterm neonates. ABO incompatibility is most common with pregnant client blood type O and neonatal blood type A or B. Therefore: preterm neonate with blood type B, pregnant client blood type O is lower risk because of preterm term neonate with blood type O, pregnant client blood type B is lower risk because of pregnant parent and neonatal blood types preterm neonate with blood type O, pregnant client blood type A is lower risk because of preterm and pregnant parent/neonatal blood types term neonate with blood type A, pregnant client blood type O is at highest risk due to term and pregnant parent and neonatal blood types.

At the birth of a high-risk newborn, what is the nurse's priority action to prevent cerebral hypoxia?

At birth, maintaining adequate respirations is the priority to prevent cerebral hypoxia. Cerebral perfusion and cardiac activity are dependent on adequate respiratory effort. Thermoregulation is important at birth, but it does not prevent cerebral hypoxia.

A newborn's condition is not improving after intubation. What assessment by the nurse would identify a possible problem?

Auscultate for bilateral breath sounds. If breath sounds are absent on one side, the endotracheal (ET) tube is malpositioned and needs to be repositioned. Retractions are consistent with respiratory distress and the need for resuscitation. A blood gas might confirm inadequate ventilation but would not identify the problem.

How does the nurse position the infant experiencing respiratory difficulty?

Positioning the infant on the back allows bilateral lung expansion. Elevating the head 15 degrees enhances movement of the diaphragm. Positioning the infant on the side or on the stomach restricts lung expansion.

The nurse begins frequent oral feedings for a small-for-gestational-age newborn to prevent which occurrence?

Intermittent oral feedings are initiated to prevent hypoglycemia as the newborn now must assume control of glucose homeostasis. Hydration and frequent monitoring of hematocrit are important to prevent polycythemia. Resuscitation and suctioning are used to manage meconium aspiration. Immediate resuscitation is used to manage asphyxia.

Which condition may cause intrauterine asphyxia? Select all that apply. 682

Conditions such as cord compression, placental abruption, and intrauterine growth restriction alter uteroplacental blood flow and may cause intrauterine asphyxia. Gestational diabetes may cause fetal hyperinsulinemia, and group B strep infection may cause intrauterine infection or PROM/preterm labor.

A 35-year-old client has just given birth to a healthy newborn during her 43rd week of gestation. What should the nurse expect when assessing the condition of the newborn?

Infants born after 42 weeks of pregnancy are postterm. These infants are at a higher risk of swallowing or aspirating meconium in utero or after birth. As soon as the infant is born, the nurse usually suctions out the secretions and fluids in the newborn's mouth and throat before the first breath to avoid aspiration of meconium and amniotic fluid into the lungs. Seizures, respiratory distress, cyanosis, and shrill cry are signs and symptoms of infants with intracranial hemorrhage. Intracranial hemorrhage can be a dangerous birth injury that is primarily a problem for preterm newborns, not postterm neonates. Yellow appearance of the newborn's skin is usually seen in infants with jaundice. Tremors, irritability, high-pitched or weak cry, and eye rolling are seen in infants with hypoglycemia.

A 33-week-gestation infant has just been born. The child's heartbeat is not audible. What is the priority nursing intervention?

Depression of the sternum with both thumbs 1 to 2 cm at a rate of 100 times per minute If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats per minute, closed-chest massage should be started. Hold the infant with fingers encircling the chest and wrapped around the back and depress the sternum with both your thumbs, on the lower third of the sternum approximately one third of its depth (1 or 2 cm) at a rate of 100 times per minute. If the pressure and the rate of massage are adequate, it should be possible, in addition, to palpate a femoral pulse. If heart sounds are not resumed above 60 beats per minute after 30 seconds of combined positive-pressure ventilation and cardiac compressions, intravenous epinephrine may be prescribed. Following cardio-resuscitation, newborns need to be transferred to a transitional or high-risk nursery for continuous cardiac surveillance to be certain cardiac function is maintained.

A nurse in the hospital is caring for a client at 37 weeks' gestation who experienced premature rupture of the membranes (PROM) more than 24 hours prior to coming to the hospital. The client presents with a fever of 100.4°F (38°C). Complete the following sentence(s) by choosing from the lists of options. Due to the client's PROM more than 24 hours prior to arriving to the hospital, the nurse determines the client is at risk for contracting group b strep and should plan to administer IV antibiotics to prevent complications

Group B streptococcus infection is a bacterial infection that can be transmitted to the fetus during labor. This can have cause serious complications to the newborn, including respiratory distress and sepsis. Group B streptococcus infection can be transmitted to the fetus during labor. The client is at risk for contracting group B streptococcus due to premature rupture of membranes (PROM) more than 24 hours prior to arriving at the hospital. The nurse will plan to administer intravenous antibiotics to the client prior to birth of the fetus. Chlamydia, trichomoniasis, and bacterial vaginosis are sexually transmitted infections (STIs). Unlike group B streptococcus infection, these infections are not transmitted to the fetus during labor. As STIs, the client is not at risk for contracting these infections because of PROM. Metronidazole is an anti-infective that is used to treat bacterial vaginosis, not group B streptococcus. Probiotics are used to maintain natural flora in the gastrointestinal (GI) system, not to treat group B streptococcus. Fluconazole is used to treat vaginal candidiasis, not group B streptococcus infections.

A newborn is determined to have an injury to the brachial plexus. Which condition should the nurse include when preparing a teaching session for the parents?

Injury to the brachial plexus results in Erb palsy or a paralysis of the arm caused by injury to the upper group of the arm's main nerves. Bulbar palsy is due to a lesion that impairs function of cranial nerves IX, X, XI, and XII. It is not birth related. Bell palsy causes temporary facial paralysis, sometimes seen when forceps are used to assist the birth. Cerebral palsy is caused by hypoxia brain injury.

In pulse oximetry for a newborn, what is the percentage of oxygen that is considered abnormal?

Oxygen saturations below 80% are considered abnormal in a newborn. This indicates that the blood has poor oxygen content.

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point?

It's important the newborn placed in an elevated position following administration by elevating the head of the incubator or warmer and the infant's airway is not suctioned for as long as safely possible after administration of surfactant to help it reach the lower lung areas and to avoid suctioning the drug away. A blood sample may be taken to rule out a streptococcal infection, which mimics the signs of RDS, but this would have been done before administration of surfactant. The infant should not be placed supine in a radiant heat warmer at this time but should be held in an upright position.

The nurse prepares to assess a newborn who is considered to be large-for-gestational-age (LGA). Which characteristic would the nurse correlate with this gestational age variation?

LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb, 13 oz (3,997 g) at term.

A nurse in the hospital nursery cares for a preterm newborn, born at 30 weeks' gestation. The newborn had an APGAR score of 6 at 1 minute (1 point for color, 1 point for respiratory effort, 1 point for muscle tone, 1 point for reflex, 2 points for heart rate) and 8 at 5 minutes. The newborn has a lot of vernix on the whole body, acrocyanosis of the hands, a glucose level of 40 mg/dl (2.22 mmol/l), and a temperature of 96.1°F (35.6°C). To prevent problems for the newborn, the action that the nurse must implement first is dry newborn to prevent hypothermia followed by observe for respiratory distress next.

Lung maturity does not occur until week 37 of gestation, so preterm newborns, which are newborns born prior to 37 weeks, are at high risk for respiratory distress and may require surfactant. Preterm newborns are at high risk for respiratory distress due to undeveloped lungs and a lack of surfactant. Preterm newborns are at risk for hypothermia. Nursing interventions are to dry the newborn, change the blanket, and apply the hat. The preterm newborn is at risk for hypothermia, but this is not the best answer. Nursing interventions that support respiratory function should be a priority. The preterm newborn is at risk for hypoglycemia, not hyperglycemia. A glucose level of 40 mg/dl (2.22 mmol/l) is within normal range for a newborn. Acrocyanosis (bluish discoloration of the extremities) is a normal finding in a newborn.

Which finding is indicative of hypothermia of the preterm neonate?

Nasal flaring is a sign of respiratory distress. Neonates with hypothermia show signs of respiratory distress (cyanosis, increased respirations, low oxygen saturation, nasal flaring, and grunting). The other choices are normal findings.

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which condition?

Oxygen administration is a common therapy in the neonatal intensive care unit, though the normal oxygen concentration for a preterm infant remains unknown. Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy of prematurity (ROP) and further respiratory complications in the preterm newborn (Martin & Deakins, 2020). For these reasons, oxygen should be used judiciously to prevent the development of further complications. A guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn. Current common practice is to maintain oxygen saturation levels in the high 80s to mid-90s, though a wide variation in practice may still occur. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area.

A 20-year-old client gave birth to a baby boy at 43 weeks' gestation. What might the nurse observe in the newborn during routine assessment?

Postterm babies are those born past 42 weeks' gestation. These babies often appear wrinkled and old at birth. They often have long fingernails and hair, dry parched skin, and no vernix caseosa. Both the quantity of lanugo and the amount of vernix decrease with gestational age. Undescended testes are usually not seen in postterm newborns; however, they are highly prevalent in preterm infants.

A nurse assisting in a birth notices that the amniotic fluid is stained greenish black as the neonate is being born. Which intervention should the nurse implement as a result of this finding?

Provide supplemental oxygen and monitor respiratory status When the amniotic fluid is stained greenish black, the neonate is at risk for meconium aspiration syndrome (MAS). Treatment for MAS depends on severity, but standard guidelines include supplemental oxygen and close monitoring of respiratory status. Additional treatment depends on the severity of respiratory compromise. The health care provider would determine if additional treatment is needed. The nurse should not administer oxygen under pressure (bag and mask) until the neonate has been intubated and suctioned, so the pressure of the oxygen does not drive small plugs of meconium farther down into the lungs, worsening the irritation and obstruction. Gently shaking the neonate and flicking the sole of the foot are methods of stimulating breathing in a neonate experiencing apnea.

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition?

Retinopathy of prematurity (ROP) is a complication that can occur when high concentrations of oxygen are given during the course of treatment for respiratory distress syndrome (RDS). ROP is caused by separation and fibrosis of the retinal blood vessels and can often result in blindness.

A nurse is providing care to a large-for-gestational-age newborn. The newborn's blood glucose level was 32 mg/dl one hour ago. Breastfeeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dl. Which action would the nurse do next?

Supervised breastfeeding or formula feeding may be the initial treatment options in asymptomatic hypoglycemia. However, symptomatic hypoglycemia should always be treated with frequent breast or formula feedings or dextrose gel massaged into the buccal mucosa. If hypoglycemia persists, then intravenous dextrose may be needed. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dl. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

The nurse observes a neonate born at 28 weeks' gestation. Which finding would the nurse expect to see?

The ear has a soft pinna that is flat and stays folded. Pale skin with no vessels showing through and 7 to 10 mm of breast tissue are characteristic of a neonate at 40 weeks' gestation. Creases on the anterior two-thirds of the sole are characteristic of a neonate at 36 weeks' gestation.

What is the correct sequence of events in a neonatal resuscitation?

The infant is dried to prevent brown fat metabolism and acidosis. An airway is established to allow interventions to expand the lungs. Then ventilation is initiated.

At birth, the newborn was at the 8th percentile with a weight of 2350 g and born at 36 weeks' gestation. Which documentation is most accurate?

The infant was a preterm, low-birth-weight and small-for-gestational-age Born at 36 weeks' gestation is a preterm age (under 37 weeks). The infant was a low birthweight (under 2500 g) and small-for-gestational-age at the 8th percentile (under the 10th percentile). The other documentation is not accurate.

The preterm neonate has been in an incubator and is in medically stable condition and gaining weight. The nurse is preparing the neonate for transfer to an open cot. What will the nurse include in the care plan for this process? Select all that apply.

The nurse should dress the neonate because the neonate will be in an open cot (sleeper, hat, light blanket); the nurse should also gradually decrease the incubator temperature every 30 minutes until room temperature is reached. The nurse should also assess the neonate's temperature every 30 minutes during the transition. The incubator should not be moved to a sunny window, because this action can increase incubator temperature and will not show the neonate's tolerance of the transition. Bathing can cause cold stress and should be avoided until after the transition is complete and the neonate shows signs of thermoregulation.

When reviewing the medical record of a newborn who is large-for-gestational-age (LGA), which factor would the nurse identify as having increased the newborn's risk of being LGA?

The nurse should identify maternal pregravid obesity as a risk factor for the development of LGA newborns. The other risk factors for the development of LGA newborns include fetal exposure to high estrogen, excess weight gain during pregnancy, gestational diabetes, and high maternal birth weight.

A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)?

The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration.

At birth, an infant is below average in weight, length, and head circumference and has a high hematocrit level. Which problem would the nurse assess for in this infant? Select all that apply.

This infant is exhibiting signs of intrauterine growth retardation. Infants who are small for gestational age have problems with thermoregulation, hypoglycemia, and hyperbilirubinemia and have prolonged acrocyanosis.

What action by the nurse provides the neonate with sensory stimulation of a human face?

To allow the infant to see a human face, assist the mother to assume an en face position with the infant. Mother and child need to be in the same plane and about 6 to 10 inches (15 to 25 cm) apart. Looking through the isolette dome or porthole distorts the image. Infants need to see objects within 12 inches (30 cm) to focus clearly.

Which nursing interventions promote healthy development of the preterm neonate? Select all that apply.

To promote development, the nurse provides nonnutritive sucking, quiet hours, covers the incubator to minimize external stimulation, and positions the infant on the side with extremities flexed and supported or nested.

When preparing to resuscitate a preterm newborn, the nurse would perform which action first?

When preparing to resuscitate a preterm newborn, the nurse should position the head in a neutral position to open the airway. Hyperextending the newborn's neck would most likely close off the airway and is inappropriate. Positive pressure ventilation would be used before endotracheal tube (ETT) insertion. ETT insertion is used if the newborn remains apneic or positive pressure ventilation is ineffective. Epinephrine is given after chest compressions are initiated.

What is a typical feature of a small-for-gestational-age (SGA) newborn that differentiates it from a preterm baby with a low-birth-weight?

ability to tolerate early oral feedings Unlike preterm babies with low birth weights, a small-for-gestational-age baby can safely tolerate early oral feeding. It usually has a coordinated sucking and swallowing reflex. Decreased muscle mass, decreased body temperature, and an angular and pinched face are features common to both an SGA baby and a preterm baby.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?

encourage parents to touch their newborn The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn?

greater body surface area in proportion to weight Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.

An infant who is diagnosed with meconium aspiration displays which symptom?

intercostal and substernal retractions Meconium aspiration is when the infant passes the first stool in utero and some of stool particles are ingested into the lungs at birth. This can cause the infant to be in distress displayed by mild cyanosis, tachypnea, retractions, hyperinflated chest, and hypercapnia.

A neonate is born at full-term after a precipitous labor and birth (above). What should the nurse do next in the neonatal resuscitation?

provide positive pressure ventilation The neonate has not responded to the initial resuscitation steps of positioning or stimulation, and the infant's heart rate is lower than 100 beats/min with no respiratory effort. Positive-pressure ventilation is required to ventilate the lungs. Bulb suctioning is not indicated unless secretions are present. Initial positive-pressure ventilation should be started with room air (21% oxygen) and oxygen only titrated if oxygen saturation remains low after effective ventilation. IV glucose, if required, should wait until urgent oxygenation needs are addressed.

A preterm neonate born at 30 weeks is gavage-fed breast milk. The nurse offers a pacifier to the neonate during gavage feedings. What does the nurse explain to the parents as the rationale for the pacifier use? Select all that apply.

provides oral stimulation, promotes digestion, practices effective sucking.

A newborn girl who was born at 38 weeks' gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification?

term, small-for-gestational age, and low birth-weight infant Infants born before term (before the beginning of the 38th week of pregnancy) are classified as preterm infants, regardless of their birth weight. Term infants are those born after the beginning of week 38 and before week 42 of pregnancy. Infants who fall between the 10th and 90th percentiles of weight for their gestational age, whether they are preterm, term, or postterm, are considered appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are considered small-for-gestational-age (SGA). Those who fall above the 90th percentile in weight are considered large-for-gestational-age (LGA). Still another term used is low-birth-weight (LBW; one weighing under 2500 g at birth). Those weighing 1000 to 1500 g are very-low-birth-weight (VLBW). Those born weighing 500 to 1000 g are considered extremely-low-birth-weight infants (ELBW).