Chapter 13 Preterm and Postterm Newborns

Necrotizing enterocolitis (NEC)

Acute inflammation of the bowel that leads to bowel necrosis

What is the treatment for hypocalcemia?

Administering intravenous calcium gluconate

What is the prognosis for preterm infant

- growth rate nears the tern infant by the second year of life, but very low birth rate babies may never catch up, especially if chronic illness, insufficient nutritional intake, or inadequate care giving has occurred

Problems associated with postterm delivery

- asphyxia cause by chronic hypoxia while in uterus because of deteriorating placenta - meconium aspiration - poor nutritional status - increase in red blood cell production - difficult delivery because of increase size of the infant - birth defect - seizes as a result of hypoxic state

What happen with immature kidneys

- cannot eliminate body waste effectively - electrolyte imbalance and disturbed acid base relationship - dehydration - tolerance to salt limited - susceptibility to edema increased

Growth and development of the preterm infant are based on?

- current age minus the number of weeks before term the infant was born - the calculation helps prevent unrealistic expectations for the infant example : born at 36 weeks gestation , a 1 month old infant would be at a newborn's achievement level

Why is this position help the preterm infant?

- decreases respiratory effort - improves oxygenation - promotes more organized sleep pattern - lessen physical activity that burns up energy needed for growth and development

Why are preterms at risk for developing sepsis

- immaturity of many body systems - liver is immature poor formation of antibodies - body enzymes are inefficient - maternal infection or complications during labor

Nursing goal for preterm infant

- improve respiration , maintain body heat, conserve energy, prevent infection, provide proper nutrition and hydration , give good skin care, observe and record observations, support and encourage parents

Symptoms of sepsis are

- low temp - lethargy or irritability - poor feeding - respiratory distress

Specific nursing resposiblity for Necrotizing enterocolitis (NEC)

- observe VS - maintain infectious control technique - carefully resume oral fluids as ordered - measure abdomen and listed to bowel sounds

Why are parental or gavage feeding sometimes required for pretem infants?

- stomach capacity small - sphincter muscles on either end are immature - increase risk for regurgitation and vomiting - sucking and swallowing reflexes are immature -ability to absorb fat poor - increase need for glucose and other nutrients to promote growth and prevent brain damage

Nursing care with immature kidneys

- weight diaper per hospital procedure - urine output should be between 1- 3 ml/kg/hr - observe for sign dehydration - document status of fontanels, tissue turgor, weight, and urinary output

Sign and symptoms of cold stress

-Increase respiratory rate with periods of apnea - decrease skin temp - bradycardia - mo - Mottling of skin - lethargy Will have an increase need for oxygen and glucose

Treatment of sepsis is?

-administration of IV antibiotics - maintain warmth and nutrition - Close monitor VS - Cluster care to conserve energy - follow standard precautions

what factors cause a preterm infant to lose heat

-lack of brown fat , bodies insulation - excessive heat loss from radiation from a surface area that is large in portion to the body - the heat regulation center of the brain is in mature - sweat glands are not functioning to capacity -preterm infant is inactive, has muscles that are weak and less resistant to cold, unable to shiver -preterm body position is one of leg extension -high metabolism prone to low blood glucose levels

Care of infant with RDS

-monitor vital sounds - minimal handling to help conserve energy(cluster care) - observe for sign of under or over hydration -Oxygen therapy, monitor pulse oximety , infant on supplemental oxygen is at high risk for oxygen toxicity

Causes of preterm births

-multiple births -Maternal illness ( GH, UTI, preclampsia) -placental abnormalities (placenta previa, premature separation of the placenta from uterine wall

If born premature what effect doe this have on the lungs?

-muscles that move the chest are not fully developed -abdomen is distended, creating pressure on the diaphragm - stimulation of the respiratory center in the brain is immature -gag and cough reflex are weak because immature nerve supply

Nurse care related to nutrition

-observe and record bowel sounds - foe gavage feeding , aspiration of gastric content prior to feeding is important. If no residual received , it's safe to start the next feeding . If higher than ordered limit feeding may need to be held

Nursing care of a posttern newborn

-observe for respiratory distress(usually because of aspiration of merconium stained amniotic fluid) - hypoglycemia cause by depleted glucose stores) - hyperbilirubinemia (as a result of polycythemia) - may be placed in incubator because fat stores have been used in utero for nourishment and the infant is vulnerable to cold stress.

Symptoms of respiratory distress

-respiration increase to 60 breaths per min - tachypnea are accompanied by gruntlike sounds, nasal flaring, cyanosis, and intercostal and sternal retraction. -Edema, lessatude, and apnea as condition becomes more severe -mechanical ventilation may be required

The urine output should be between ____ and ____

1 and 3 mL/kg/hr.

What are plasma glucose in term infant

<40 mg/dl

The nurse records the temperature of the infant and the incubator every _______.

2 hours.

Apnea is defined as the cessation of breathing for ____ seconds or longer.

20

In late-onset jaundice of the breastfed infant, the breast milk itself may inhibit conjugation of bilirubin, and therefore formula may be substituted for ____ to ____ hours to reduce bilirubin levels.

24 to 48

The total serum bilirubin level typically peaks ___ to ___ days after birth.

3 to 5

If the infant is gavage fed, the tube is replaced every __ to ____ days.

3 to 7

The ability to coordinate breathing, sucking, and swallowing does not develop before ___ weeks of gestation.

34

The ability to coordinated breathing, sucking and swallowing develops at how many weeks?

34 weeks Depends on how well developed for feeding

The temperature of the incubator is adjusted so that the infant's body temperature is at an optimal level which is what?

36.2° to 37° C [97.1° to 98.6° F

For the preterm infant this is less than ___weeks.

37

Term

38 to 42 weeks

The full term infant is one born between _____ and ____

39 and 40 weeks, 6 days

How many day after birth to breast fed infants show jaundice?

4 days

The postterm infant is born beyond ____ weeks

42

There must be at least ____ g/dL of desaturated hemoglobin (unoxygenated blood) to produce clinical cyanosis.

5

A relative humidity of ___% or higher is desirable.

60

In preterm newborns, surfactant can be administered via endotracheal (ET) tube at birth or when symptoms of RDS occur, with improvement of lung function seen within ___ hours.

72

A pulse oximeter saturation level of _____% or higher is normal

92

What are the normal saturation levels

92% or above

Set alarm switch to minimum acceptable oxygen saturation (Sao2) of approximately ___ to ___ %

92%-95%.

What are plasma glucose in preterm infant

< 30 mg/dl

An early term infant is born between ____ and ____.

An early term infant is born between 37 weeks and 38 weeks, 6 days.

An increase of more than ______ mg/dL in 24 hours or a bilirubin level greater than _____ mg/dL requires careful investigation

An increase of more than 5 mg/dL in 24 hours or a bilirubin level greater than 12.9 mg/dL requires careful investigation

One standardized method used to estimate gestational age within 1 to 2 weeks is the ____ ____ system

Ballard scoring system

Why is a skin probe used to monitor the temperature of preterm infants?

Because the infant's skin temperature will decrease before the core temperature falls.

_________ _______ is the toxic response of the lung to oxygen therapy.

Bronchopulmonary dysplasia

hypoxemia

Deficiency of oxygen in the arterial blood

What are three symptoms of respiratory distress syndrome that signify that it is more severe?

Edema, lassitude, and apnea

The infant's ability to absorb ____ is poor .

Fats. These include fat-soluable vitamins

What may first be done to stimulate breathing?

Gentle rubbing of the infant's feet, ankles, and back

___ _____ refers to the actual time, from conception to birth, that the fetus remains in the uterus.

Gestational age

What should not be given to the infant who has jaundice? Why?

Glucose water feedings should not be offered to the infant, because this practice may decrease milk intake and can serve to further increase bilirubin levels

what should the nurse monitor closely when infant is given IV calcium gluconate?

Heart rate report if Bradycardia occurs

_____ hypocalcemia usually occurs about age 1 week in newborn or preterm infants who are fed cow's milk.

Late

Factors implicated for necrotizing enterocolitis (NEC) include a diminished blood supply to the lining of the bowel wall because of ______ or ______ that causes a decrease in protective mucus and results in bacterial invasion of the delicate tissues.

Hypoxia or sepsis

Treatment of respiratory distress

Increase surfactant production by giving the mother injections of corticosteroids such as betamethasone 1 or 2 days before delivery

List four advantages to propping the infant on the side or placing the infant prone

It can decrease respiratory effort, improve oxygenation, promote a more organized sleep pattern, and lessen physical activity that burns up energy needed for growth and development.

___ _____ is a method of care for preterm infants that uses skin-to-skin contact.

Kangaroo care

_______ refers to how well developed the infant is at birth and the ability of the organs to function outside the uterus.

Level of maturation

Hypocalcemia

Low calcium in blood ("hypo" below ") ("calcemia" calcium in blood)

_________ is an acute inflammation of the bowel that leads to bowel necrosis.

Necrotizing enterocolitis (NEC)

Cold stress increases the need for what two things?

Oxygen and glucose

______ jaundice is more serious, occurs within 24 hours of birth, and is secondary to an abnormal condition such as ABO-Rh incompatibility

Pathological

Plasma glucose levels lower than _____ mg/dL indicate hypoglycemia in a term infant, and in a preterm infant, lower than _____ mg/dL.

Plasma glucose levels lower than 40 mg/dL indicate hypoglycemia in a term infant, and in a preterm infant, lower than 30 mg/dL.

_______ refers to the infant showing characteristics of the postmature syndrome.

Postmaturity

_______ is a result of lung immaturity, which leads to decreased gas exchange.

RDS type 1

Surfactant begins to appear in the fetal alveoli at approximately ____ weeks of gestation and is at a level to enable the infant to breathe adequately at birth by _______ weeks of gestation.

Surfactant begins to appear in the fetal alveoli at approximately 24 weeks of gestation and is at a level to enable the infant to breathe adequately at birth by 34 weeks of gestation.

List three methods used to evaluate the gestational age of the newborn infant.

The Ballard score, the estimated gestational age based on the mother's last normal menstrual period, and ultrasound evaluations

List four specific examples of immature body systems that puts preterm newborns at risk for developing sepsis.

The liver of the preterm infant is immature and forms antibodies poorly. Body enzymes are inefficient. There is little or no immunity received from the mother, and stores of nutrients, vitamins, and iron are insufficient.

How do you determine the urine output of an infant?

The nurse should weigh the dry diaper and subtract its weight from the infant's wet diaper

List eight physical characteristics of the preterm infant.

There is a lack of subcutaneous fat. Fine hair (lanugo) covers the forehead, shoulders, and arms. The cheeselike vernix caseosa is abundant. The extremities appear short. The soles of the feet have few creases. The abdomen protrudes. The nails are short. The genitalia are small.

Superficial veins may be seen beneath the ___ and ____

abdomen and scalp.

Sign and symptons Necrotizing enterocolitis (NEC)

abdominal distention, bloody stool, diarrhea, and bolious vomitus

List four signs of NEC

abdominal distention, bloody stools, diarrhea, and bilious vomitus.

Gestational Age

actual time from conception to the birth that ftus remains in uterus

Treatment for sepsis of the preterm infant involves what three things?

administration of intravenous antimicrobials, maintenance of warmth and nutrition, and close monitoring of vital signs, including blood pressure.

During the second half of the pregnancy what changes occur in the fetal lungs

alveoli (air sacs) enlarge and bring them close to the capillaries in the lungs

The severely ______ infant may have severe hypoxia yet not manifest clinical cyanosis.

anemic

Treatment for Necrotizing enterocolitis (NEC)

antibiotics and use of parental nutrition to rest the bowels surgical removal of the necrosed bowel may be indicted

what are risk with bronchopulmonary dysplasia

atelectasis (collapsed lung) , edema and thickening of the membrane of the lung interferes with ventilation often results in prolonged dependency on supplemental oxygen and ventilators and has long term complications

Why are formulas designed for preterm infants not well tolerated by infants older than 34 weeks of gestation or term infants?

because hypercalcemia may develop.

Why are preterm newborns at risk for developing sepsis

because of the immaturity of many body systems.

Why are premature infants at risk for Retinopathy of prematurity (ROP)?

because their immature retinas are incompletely vascularized at birth.

If insufficient amounts of surfactant are detected through amniocentesis, it is possible to increase its production by giving the mother injections of corticosteroids such as ________.

betamethasone

With jaundice, the liver is unable to clear the blood of ______ pigments that result from the normal postnatal destruction of red blood cells.

bile

late preterm infant (near term infant )

born between 24 and 36 weeks also considered high risk regardless of weight

The posterm infant

born beyond 42 weeks gestation placenta does not function well after a certain point can result in fetal distress

During intravenous therapy of calcium gluconate, the nurse should monitor the infant for what?

bradycardia.

There is more evidence of jaundice in infants who are ______..

breastfed

Formulas designed for the term infant are not well tolerated by preterm infants because they are a burden to their kidneys and can cause what sort of problems?

central nervous system problems

apnea

cessation of respiration for 20 sec or longer

Infants born to mothers who are ______ or who have had low ______ intake are also at risk for developing early hypocalcemia.

diabetic: vitamin D

What can alter surfactant production?

during cold stress hypoxia poor tissue profusion

In _____ hypocalcemia the parathyroid fails to respond to the preterm infant's low calcium levels.

early

gavage

feeding by means of a stomach tube or a tube passed through the nose, pharynx, and esophagus into stomach

After birth, often accompanied by high levels of oxygen required for the infant's survival, the retina completes an abnormal vascularization process that causes _______ tissue to form behind the lens of each eye resulting in blindness and retinal detachment

fibrous

Sepsis

generalized infection of the blood

Any condition that increases metabolism increase what need?

glucose

Postterm

greater than 42 weeks

Level of maturation

how well developed the infant is at birth ability of the organs to function outside the uterus.

what is the ideal milk for preterm infant

human

Early initiation of feeding reduce the risk of ?

hyopglycemia, hyperbiliribinemia and dehydration

If the hemoglobin present is an abnormal fetal hemoglobin, ________ can be present even when the pulse oximeter shows a normal reading, because fetal hemoglobin does not readily release oxygen to the tissues and end organs

hypoxia

Infants stressed by what three conditions are at high risk for early hypocalcemia.

hypoxia or birth trauma or who are receiving sodium bicarbonate

Jaundice

immature liver liver is unable to clear the blood of bile pigment that results from normal postnatal destruction of red blood cells causes skin and whites of the eyes to assume a yellow orange cast

Where is the skin probe placed?

in the right upper quadrant of the abdomen.

neonatal hypoxia

inadequate oxygenation at the cellular level in a new born infant

What increase of bilirubin require investigation?

increase >5 mg/dl in 24 hours or level greater than 12.9 mg/dl Usually peak 3 to 5 days after birth

Fragile capillaries of the head are particularly susceptible to injury during delivery, causing _____ ____.

intracranial hemorrhage.

thermoregulation

involves maintaining a stable body temperature and preventing hypothermia and hyperthermia stable body temperature is essential for survival and management of preterm infants

What is apnea in the pretterm newborn believed to be related to?

is believed to be related to immaturity of the nervous system.

Respiratory distress syndrome (RDS type 1) (hyaline membrane disease)

result of immature lung, leads to decreased gas exchange surfactant is a fatty protein that is high in lecithin, it necessary for the lung to absorb oxygen

The goals of treatment for hyperbilirubinemia are to prevent_______ and to avoid _____.

kernicterus (a serious neurological complication that can cause brain damage, which is also known as bilirubin encephalopathy) and to avoid the continued increase of bilirubin levels in the blood.

late term infant is one born between _____ and _____..

late term infant is one born between 41 weeks and 41 weeks, 6 days.

Surfactant is high in _______, a fatty protein necessary for the absorption of oxygen by the lungs

lecithin

Testing for the ______________ ratio provides information about the amount of surfactant in amniotic fluid.

lecithin/sphingomyelin (L/S)

preterm

less than 38 weeks

Physical characteristic of a posttern newborn

long and thin , weight may have been lost , skin is loose(especially around buttock and thigh), little lanugo or vernix caseosa, skin is dry, cracks and peels, nails are long and may be stained from meconium, thick head of hair , looks alert

List 8 physical characteristics of the postterm infant.

long, thin, loose skin, little lanugo, little vernix, dry, cracked skin, thick head of hair, and long nails.

hypoglycemia common in preterm

low blood sugar ("hypo" less than ") ("glycemia" sugar in blood)

what should the nurse monitor and report if there is a is deficient in the blood?

neurological status report bulging fontanells, lethargy, poor feeding, and seizures Bed should be in slight fowlers position necessary stimulation that can cause increase intercranial pressure should be avoided

Nursing care jaundice

observe skin , sclera, and mucus membranes for sign of jaundice - report progression from face to abdomen and feet - monitor and report and abnormal lab results

What is the leading cause of death in the first year of an infant?

preterm birth

goal of treating jaundice

prevent kernicterus by preventing the rising bilirubin levels from staining the basil nuclei of the brain

Failure of the alveoli to enlarge is called ?

previability

what is deficient in the blood that cause preterm infants more prone to bleeding

prothombin ( a factor of the clotting mechanism)

Preterm infants are more prone to bleeding than full-term infants because their blood is deficient in _______, a factor of the clotting mechanism.

prothrombin

List three things that nurses observe for in a postterm infant.

respiratory distress (usually because of aspiration of meconium-stained amniotic fluid), hypoglycemia (caused by depleted glycogen stores), and hyperbilirubinemia (as a result of polycythemia).

In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the _____ year.

second

Retinopathy of prematurity

separation of fibrosis of the retina, can lead to blindness form too much oxygen leading cause of blindness in infant that weight 3.2 lbs or less Monitoring pulse ox is priority Key to preventing is preventing preterm cryosurgery may reduce long-term complications of ROP

How do you position a preterm infant?

side or prone with head of mattress slightly elevated (in this position abdomen does not press against the diaphragm and impede breathing)

kangaroo care

skin to skin contact skin warms and calms the child and the contact promotes bonding

Physical characteristic of a preterm infant

skin transparent and loose superficial veins may be seen beneath the abdomen and scalp lack of subcutaneous fat fine hair (lanugo) cover the forehead, shoulder, and arms vernix caseose abudant extremities appear short soles of the feet have few creases abdomen protrudes nails are short genitalia are small girl the labia majora may be open

ballard score

standard method used to determine gestational age based on external characteristics and neurological development

When gentle rubbing of the infant's feet, ankles, and back doesn't work, what may be done?

suctioning of the nose and mouth and raising of the infant's head to a semi-Fowler's position usually facilitates breathing.

With RDS type 1, there is a deficient synthesis or release of __________.

surfactant

Treatment of preterm infant with respiratory distress

surfactant can be administered via ET tube at birth or when symptoms occur improvement usually seen within 72 hours

Why are preterm newborns positioned on the side or prone, with the head of the mattress slightly elevated, if not contraindicated?

the abdominal contents do not press against the diaphragm and impede breathing.

The Ballard scoring system is based on what two things?

the infant's external characteristics and neurological development

Define pulse oximetry

the measure of oxygen on the hemoglobin in the circulating blood divided by the oxygen capacity of the hemoglobin.

In general, growth and development of the preterm infant are based on current age minus __________.

the number of weeks before term that the infant was born; for example, if born at 36 weeks of gestation, a 1-month-old infant would be at a newborn's achievement level.

If a residual of liquid contents is aspirated before the feeding is started, what should be done?

the physician should be notified before proceeding to feed the infant.

Calcium is transported across the placenta throughout pregnancy, but in greater amounts during the ______ trimester.

third

what is bronchopulmonary dysplasia?

toxic response of the lung to oxygen therapy

What is the skin like in a preterm newborn?

transparent and loose.

Sign and symptoms of hypoglycemia in preterm infant

tremors, weak cry, lethargy, convulsions, plasma glucose levels lower than 40 mg/dl(term) 30 md/dl (preterm)

Maintaining a sufficient level of ______ and avoiding excessively high concentrations of ______ may help to prevent this condition.

vitamin E;oxygen

The following problems are associated with postmaturity: (7)

•Asphyxia caused by chronic hypoxia while in the uterus because of a deteriorated placenta •Meconium aspiration: hypoxia and distress may cause relaxation of the anal sphincter, and meconium can be aspirated into the fetal lungs •Poor nutritional status; depleted glycogen reserves cause hypoglycemia •Increase in red blood cell production (polycythemia) because of intrauterine hypoxia •Difficult delivery because of increased size of the infant •Birth defects •Seizures as a result of the hypoxic state

Signs and symptoms of cold stress include the following: (5)

•Decreased skin temperature •Increased respiratory rate with periods of apnea •Bradycardia •Mottling of skin •Lethargy

Heat loss in the preterm infant results from the following factors: (7)

•Lack of brown fat, which is the body's insulation. •Excessive heat loss by radiation from a surface area that is large. (head) •The heat-regulating center of the brain is immature. •The sweat glands are not functioning to capacity. •The preterm infant is inactive, has muscles that are weak and are less resistant to cold, and cannot shiver •Legs are extended. This increases the surface area exposed to the environment and increases heat loss. •Metabolism is high, and the preterm infant is prone to low blood glucose levels (hypoglycemia).

Signs of hypoglycemia in the preterm infant include the following: (5)

•Tremors •Weak cry •Lethargy •Convulsions •Plasma glucose level lower than 40 mg/dL (term) or 30 mg/dL (preterm)