OB ATI: Chapter 27 - Assessment and Management of Newborn Complications

Tracheoesophageal fistula/atresia clinical manifestations

Abdominal distension, rattling respirations, excessive salivation, three C's (coughing, choking, and cyanosis)

What do we do for newborns addicted to cocaine?

Avoid eye contact, use vertical rocking, and pacifier

How often should you reposition?

2 hours

When are eyes closed?

22-24 weeks

Large for Gestational Age (LGA)

> 4,000 g (8 lb, 12 oz)

When do we prescribe phototherapy?

>15 mg/dL prior to 48 hr of age >18 mg/ dL prior to 72 hrs >20 mg/dL at any time

A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? (Select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face

A, C, D

Birth trauma/injury type: Plexus

Brachial plexus injury, Klumpke's palsy

How do we obtain hemoglobin concentration measurements?

Cord blood

How often should you feed baby?

every 3-4 hours

Bilirubin levels rise by what 3 main mechanisms

1) Increased production 2) Decreased removal 3) Increased reabsorption

Periodic breathing

5-10 sec respiratory pauses Followed by 10-15 sec compensatory rapid respirations

Diagnostics for RDS

ABGs - reveal hypercapnia chest x-ray

Postterm Infant

After completion of 42 weeks

Effects of phototherapy

Bronze discoloration Maculopapular skin rash Pressure areas Dehydration Elevated temp

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in this newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash

C

Acute bilirubin encephalopathy

Clinical manifestations during 1st week of life Lethargy, poor feeding, poor tone, poor Moro reflex, incomplete flexion of extremities, high-pitched cry

Nursing actions for Neonatal Infection/Sepsis

◯ Assess infection risks (review maternal health record). ◯ Monitor the newborn for clinical findings of opportunistic infection. ◯ Monitor the newborn's vital signs continuously. ◯ Monitor the newborn's I&O and daily weight. ◯ Monitor the newborn's fluid and electrolyte status. ◯ Monitor the newborn's visitors for infection. ◯ Obtain specimens (blood, urine, stool) to assist in identifying the causative organism. ◯ Initiate and maintain IV therapy as prescribed to administer electrolyte replacements, fluids, and medications. ◯ Administer medications as prescribed (broad-spectrum antibiotics prior to cultures being obtained).

Posterm Infant: Nursing Care

◯ Monitor the newborn's vital signs. ◯ Administer and monitor the newborn's IV fluids. ◯ Use mechanical ventilation if necessary. ◯ Administer oxygen as prescribed. ◯ Prepare and/or assist with exchange transfusion if hematocrit is high. ◯ Provide thermoregulation in an isolette to avoid cold stress. ◯ Provide early feedings to avoid hypoglycemia. ◯ Identify and treat any birth injuries.

Hyperbilirubinemia

Elevation of serum bilirubin levels resulting in jaundice

Risk factors for Congeital anomalies

Excessive body heat exposure Radiation exposure Premature Oligohydramnios or polyhydramnios

Nerve-plexus injuries/long bone fractures

Flaccid muscle tone of extremities

Gastroschisis

Herniation of abdominal contents through abdominal wall at umbilicus w/out sac

When do we use exchange transfusion?

If total serum bilirubin levels remain elevated after failure of intensive phototherapy

Birth trauma/injury type: Skull

Linear fracture, depressed fracture

Heroin withdrawal

Low birth weight, decreased moro reflex, hypo/hyperthermia

Phenylketonuria

Mental retardation

ABO Incompatibility

Mom with type O blood Fetus w/ types A, B, or AB

Chronic bilirubin encephalopathy/kernicterus clinical manifestations

Movement disorder, auditory dysfunction, oculomotor impairment, dental enamel hypoplasia of deciduous teeth

Risk factors for SGA

Multiple gestations Placental factors Fetal congenital infections (rubella, toxoplasmosis) etc.

Fetal alcohol spectrum disorders (FASD)

Neurodevelopmental disorder

Physical for SGA

Normal skull - reduced body dimensions Hair sparse Wide skull suture Dry, loose skin Decrased subQ fat Decreased muscle mass (cheek, butt) thin, dry, yellow, dull umbilical cord Drawn abdomen Wide-eyed, alert Hypotonia Hypoglycemia Acrocyanosis

Marijuana withdrawal

Preterm birth and meconium staining

Complications for Preterm

RDS Bronchopulmonary dysplasia Aspiration Apnea of prematurity Intraventricular hemorrhage Retinopathy Patent ductus arteriosus Necrotizing enterocolitis

Nutrition for PKU

Restrict meat, dairy products, diet drinks, and protein Aspartame avoided

when does Rh Isoimmunization develop?

Rh negative mom Rh positive fetus

Birth trauma/injury type: Spinal cord

Spinal cord transaction

SGA

describes a newborn whose birth weight is at or below the 10th percentile and who has intrauterine growth restriction.

How often should you remove phototherapy?

every 4 hours

Hypothyroidism

hypothermia, poor feeding, lethargy, jaundice, cretinism (stunted growth)

Posterm Infant: Lab Tests

◯ Blood glucose levels to monitor for hypoglycemia ◯ ABGs secondary to chronic hypoxia in utero due to placental insufficiency ◯ CBC may show polycythemia from decreased oxygenation in utero ◯ Hct elevated from polycythemia and dehydration

When can we begin oral feedings after surgery of closing the fistula and joining the two esophageal segments?

1 week after

A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate

A

Hyperbilirubenia: Nursing Care

◯ Observe the newborn's skin and mucous membranes for jaundice. ◯ Monitor the newborn's vital signs. ◯ Set up phototherapy if prescribed. ■ Maintain an eye mask over the newborn's eyes for protection of corneas and retinas. ■ Keep the newborn undressed with the exception of a male newborn. A surgical mask should be placed (like a bikini) over the genitalia to prevent possible testicular damage from heat and light waves. Be sure to remove the metal strip from the mask to prevent burning. ■ Avoid applying lotions or ointments to the skin because they absorb heat and can cause burns. ■ Remove the newborn from phototherapy every 4 hr, and unmask the newborn's eyes, checking for inflammation or injury. ■ Reposition the newborn every 2 hr to expose all of the body surfaces to the phototherapy lights and prevent pressure sores. ■ Check the lamp energy with a photometer per facility protocol. ■ Turn off the phototherapy lights before drawing blood for testing. ◯ Observe the newborn for effects of phototherapy. ■ Bronze discoloration - not a serious complication ■ Maculopapular skin rash - not a serious complication ■ Development of pressure areas ■ Dehydration (poor skin turgor, dry mucous membranes, decreased urinary output) ■ Elevated temperature ◯ Encourage the parents to hold and interact with the newborn when phototherapy lights are off. ◯ Monitor elimination and daily weights, watching for evidence of dehydration. ◯ Check the newborn's axillary temperature every 4 hr during phototherapy because temperature may become elevated. ◯ Feed the newborn early and frequently - every 3 to 4 hr. This will promote bilirubin excretion in the stools. ◯ Encourage continued breastfeeding of the newborn. Supplementation with formula may be prescribed. ◯ Maintain adequate fluid intake to prevent dehydration. ◯ Reassure the parents that most newborns experience some degree of jaundice. ◯ Explain hyperbilirubinemia, its causes, diagnostic tests, and treatment to parents. ◯ Explain that the newborn's stool contains some bile that will be loose and green. ● Administer an exchange transfusion for newborns who are at risk for kernicterus. ● Discharge Instructions ◯ Educate the parents regarding the newborn's plan of care.

Hypoglycemia: Nursing Care

◯ Obtain blood by heel stick for glucose monitoring. ◯ Provide frequent oral and/or gavage feedings, or continuous parenteral nutrition early after birth to treat hypoglycemia. ◯ Monitor the neonate's blood glucose level closely per facility protocol. ◯ Monitor IV if the neonate is unable to feed orally.

Confirmation for Congeital anomalies

Amniocentesis, chorionic villi sampling, ultrasound

Rh Incompatibility symptoms

Ascites, congested heart failure, edema, pallor, jaundice, hepatosplenomegaly, hydramnios, thick placenta, and dilation of the umbilical vein

A nurse is caring for a newborn who has suspected neonatal abstinence syndrome. Which of the following findings supports this diagnosis? A. Decreased muscle tone B. Continuous high-pitched cry C. Sleeps for 2 hr after feeding D. Mild tremors when disturbed

B

Pathologic jaundice

Before 24 hours of birth, till day 7 Levels >0.5 mg/dL/hr Peaks >13 mg/dL

Physiologic Jaundice

Benign (jaundice after 24 hours)

Medications for RDS

Beractant Suction prior to medication Avoid suctioning endotracheal tube for 1 hour

Medications for Preterm

Betamethasone (Celestone) Fetal lung development

Lab tests for Kernicterus

Bilirubin levels q 4 hr direct Coomb's test (presence of antibody-coated Rh-pos RBCs)

Preterm Newborn

Born between 20-37 weeks

Preterm: Nursing Care

◯ Perform rapid initial assessment. ◯ Perform resuscitative measures if needed. ◯ Monitor the newborn's vital signs. ◯ Assess the newborn's ability to consume and digest nutrients. Before feeding by breast or nipple, the newborn must have an intact gag reflex and be able to suck and swallow to prevent aspiration. ◯ Monitor the newborn's I&O, and daily weight. ◯ Monitor the newborn for bleeding from puncture sites and the gastrointestinal tract. ◯ Ensure and maintain thermoregulation in a newborn who is premature by using a radiant heat warmer. ◯ Administer respiratory support measures, such as surfactant and/or oxygen administration. ◯ Administer parental or enteral nutrition and fluids as prescribed (most premature newborns who are less than 34 weeks of gestation will receive fluids either by IV and/or gavage feedings). Provide for nonnutritive sucking, such as using a pacifier while gavage feeding. ◯ Minimize the newborn's stimulation. Cluster nursing care. Touch the newborn very smoothly and lightly. Keep lighting dim and noise levels reduced. ◯ Position the newborn in neutral flexion with his extremities close to his body to conserve body heat. Prone and side-lying positions are preferred to supine with body containment using blanket rolls and swaddling, but only in the nursery under monitored supervision. ◯ Protect the newborn against infection by enforcing hand hygiene and gowning procedures. Equipment should not be shared with other newborns.

RDS: Nursing Care

◯ Suction the newborn's mouth, trachea, and nose as needed. ◯ Maintain thermoregulation. ◯ Provide mouth and skin care. ◯ Correct respiratory acidosis with ventilatory support. ◯ Correct metabolic acidosis by administering sodium bicarbonate. ◯ Maintain adequate oxygenation, prevent lactic acidosis, and avoid the toxic effects of oxygen. ◯ Decrease stimuli.

SGA: Nursing Care

◯ Support respiratory efforts, and suction the newborn as necessary to maintain an open airway. ◯ Provide a neutral thermal environment for the newborn (isolette or radiant heat warmer) to prevent cold stress. ◯ Initiate early feedings. (A newborn who is SGA will require feedings that are more frequent.) ◯ Administer parenteral nutrition if necessary. ◯ Maintain adequate hydration. ◯ Conserve the newborn's energy level. ◯ Prevent skin breakdown. ◯ Protect the newborn from infection.

Blood tests for Gestational Hypertension

CBC Blood glucose, calcium, magnesium, thyroid-stimulating hormone drug screen of urine/meconium to reveal agent used by mother Hair analysis

Lab tests for Preterm

CBC - decreased Hbt and Hct urinanalysis and specific gravity Increased PT and aPPT time Serum glucose Calcium Bilirubin ABGs

S/s of abstinence syndrome (withdrawal)

CNS - Increased wakefulness, hyperactivity, increased DTR, increased muscle tone, abrasions/excoriations on face & knees, convulsions Metabolic, vasomotor, and respiratory - nasal flaring, frequent yawning, skin mottling, tachypnea, sweating, fever Gastrointestinal - poor feeding, regurgitation, diarrhea, constant sucking

Opiate withdrawal

Can last for 2-3 weeks Rapid changes in mood, hypersensitivity to stimuli, dehydration, poor weight gain

Birth trauma/injury type: Scalp

Caput succedaneum

Galactosemia

Cataracts, jaundice, cirrhosis, sepsis, mental retardation

What can survivors of Kernicterus develop?

Cerebral palsy, epilepsy, mental retardation

Diagnostics for Gestational Hypertension

Chest x-ray

Diagnostic for Preterm

Chest x-ray Head ultrasounds Echocardiography Eye exams

Medications for Neonatal Infection/Sepsis

Combination of ampicilin w/ aminoglycoside or 3rd gen cephalosporin Gentamicin sulfate (Garamycin)

Congeital anomalies

Congenital heart disease Neurological effects GI MS GU Metabolic disorders Chromosomal abnormalities

Lab for RDS

Culture and sensitivity of blood, urine, and CSF Blood glucose and serum calcium

A nurse is examining an infant who was just delivered at 41 weeks of gestation. Which of the following characteristics indicates that this infant is postterm? A. Excess body fat B. Flat areola without breast buds C. Heels movable fully to the ears D. Leathery skin

D

Can be associated with what?

Dysmaturity from placental degeneration to uteroplacental insufficiency

Birth trauma/injury type: Intracranial

Epidural/subdural hematoma, cerebral contusion

Omphalocele

Evisceration of abdominal contents into external peritoneal sac

Fetal alcohol syndrome

Facial anomalies (eyes w/ epicanthal folds, strabismus, ptosis), mouth (poor suck, small teeth, cleft lip) Deafness Abnormal palmar creases/irregular hair Organ anomalies Retardation Sleep disturbances

Facial paralysis

Facial flattening, unresponsiveness to grimace, eyes open

Tracheoesophageal atresia

Failure of esophagus to connect to stomach excessive mucous, period cyanotic episodes, abdominal distention, immediate regurgitation

What are FAS infants at risk for?

Feeding problems CNS dysfunction Behavioral difficulties Language abnormalities Future substance Delayed G&D Poor maternal-newborn bonding

Duodental atresia

First part of small bowel has not developed (closed) Stomach contents unable to pass

Erb-Duchenne paralysis (brachial paralysis)

Flaccid arm w/ elbow extended, hand rotated inward, absence of moro, sensory loss, intact grasp reflex

Cocaine withdrawal

Fussy, irritable, inconsolable

Risk factors for Preterm

GH adolescent pregnancy placenta previa etc.

Routine testing for metabolic orders

Guthrie test (PKU) - not reliable until baby ingested protein Blood & urine levels of galactose Thyroxine Cytologic studies (ex: bucal smear)

Where does jaundice normally appear

Head, progress to thorax, abdomen, extremities

Labs for LGA

Hyperbilirubinemia Hypocalcemia Blood glucose levels to monitor closely for hypoglycemia (less than 40 mg/dL).

Risk factors of Kernicterus

Increased RBC production/breakdown Rh/ABO incompatibility Decreased liver function Ineffective breastfeeding Sibling w/ jaundice Hypoglycemia Hypothermia Anoxia Premature

subarachniod hemorrhage

Irritability, seizures within 72 hrs, decreased LOC

Clinical findings of Kernicterus

Lethargy Poor suck reflex Increased sleepiness Hypertonic w/ back arching of neck and trunk high-pitch cry Fever

Clavicular fractures

Limited motion of one arm, crepitus over clavicle (crack), absence of moro reflex

Soft-tissue Injuries

Localized discoloration, ecchymosis, petechiae, edema

Neonatal Substance Withdrawal

Maternal use of substances during pregnancy

Preferred position for client w/ LGA

McRobert's position (lithotomy)

Clinical Picture of Fetal Alcohol Syndrome

Microcephaly Small palpable fissures Abnormally small eyes Thin upper lip

Complications for Small for Gestational Age Newborn (SGA)

Perinatal asphyxia, meconium aspiration, hypoglycemia, polycythemia (bone marrow disease), instability of temp.

Medications for Gestational Hypertension

Phenobarbital - Decrease CNS irritability, control seizures

Fetal alcohol syndrome (FAS)

Physical and mental disorders Results from chronic/periodic intake of alcohol

Physical assess for Hypoglycemia

Poor feeding jitteriness hypothermia diaphoresis lethargy weak shrill cry flaccid muscle tone seizures/coma irregular respirations cyanosis apnea

Tobacco

Prematurity Low birth weight Increased risk for bronchitis, pneumonia

Neonatal Infection/Sepsis (Sepsis Neonatorum)

Presence of micro-organisms or their toxins in blood/tissues during 1st month of birth

Risk factors for RDS

Preterm Perinatal asphyxia Diabetes Premature ROM Maternal hypotension CS w/out labor Hydrops fetalis (massive edema of fetus caused by hyperbilirubinemia) Maternal bleeding during 3rd trimester

Risk factors for hypoglycemia

Preterm infant LGA/SGA Stress at birth Maternal epidural anesthesia

Amphetamine withdrawal

Preterm, drowsiness, jittery, sleep disturbance, respiratory distress, frequent infections, poor weight gain, emotinal disturbances, delayed G&D

Preferred position for Preterm

Prone or side-lying

Complications of RDS

R/t oxygen therapy and mechanical ventilation Pneumothorax Pneumomediastinum Retinopathy Bronchopulmonary dysplasia Infection Intraventricular hemorrhage

Atelctasis (collapsing of portion of lung)

Result - respiratory acidosis and hypoxemia

Physical assessment of LGA

SLuggishness, hypotonic Tremors Hypoglycemia Respiratory distress Increased ICP

Hypoglycemia

Serum blood glucose level <40 mg/dL (term) <25 mg/dL (preterm) Can result in seizures, brain damage and/or death

Nutrition for Galactosemia

Soy-based formula Eliminate lactose and galactose Do not breastfeed

Physical for Neonatal Infection/Sepsis

Temp instability Suspicious drainage Abdominal distention Respiratory problems Color changes Tachycardia/bradycardia Tachypnea Low BP Irritability/seizure Poor muscle tone/lethargy

Ballard assessments for Preterm

Totalling to <37 weeks

Lab for Hypoglycemia

Two consecutive plasma glucose levels <40 mg/dL / <25 mg/dL

Dehydration

Urine output <1 mL/kg/hr Urine specific gravity >1.015 Weight loss Depressed fontanel

Overhydration

Urine output >3 mL/g/hr Urine specific gravity <1.001 Edema Increased weight gain

WITHDRAWAL acronym

Wakefulness, sleep duration <3 hours after feeding Irritability Temperature, variation, tachycardia, tremors Hyperactivity Diarrhea, diaphoresis, disorganized suck Respiratory distress, rub marks, rhinorrhea Apneic attacks, autonomic dysfunction Weight loss or failure to gain weight Alkalosis Lacrimation

Physical assessment of postterm

Wasted appearance peeling, cracked, dry skin meconium staining fingernails and umbilical cord hair and nails long alertness difficulty respirations hypoglycemia cold stress neurological manifestations

Newborns who are postmature have an increased risk for

aspirating the meconium passed by the fetus in utero.

Risk factors for Neonatal Infection/Sepsis

chorioamnionitis low birth weight PROM premature birth mecconium

Methadone withdrawal

increased seizures, sleep pattern disturbances, higher birth weights, high risk of SIDS

Respiratory Distress Syndrome (RDS)

result of surfactant deficiency in lungs - poor gas exchange and ventilatory failure

Objective Data for RDS

■ Tachypnea (respiratory rate greater than 60/min) ■ Nasal flaring ■ Expiratory grunting ■ Retractions ■ Labored breathing with prolonged expiration ■ Fine crackles on auscultation ■ Cyanosis ■ Unresponsiveness, flaccidity, and apnea with decreased breath sounds (manifestations of worsened RDS)

LGA: Nursing Care

● Nursing Care Prior to Delivery ◯ Prepare the client for a possible vacuum-assisted or cesarean birth. ◯ Prepare to place the client in McRoberts' position (lithotomy position with legs flexed to chest to maximize pelvic outlet). ◯ Prepare to apply suprapubic pressure to aid in the delivery of the anterior shoulder, which is located inferior to the maternal symphysis pubis. ◯ Assess the newborn for birth trauma, such as a broken clavicle or Erb-Duchenne paralysis. ● Nursing Care for a Newborn Who is LGA Following Delivery ◯ Obtain early and frequent heel sticks (blood glucose testing). ◯ Initiate early feedings or intravenous therapy to maintain glucose levels within the expected reference range. ◯ Provide thermoregulation with isolette care. ◯ Administer surfactant by endotracheal tube if indicated. ◯ Identify and treat any birth injuries.

Direct Coombs Test

Detect hemolytic disease

Joint dislocations

Flaccid muscle tone

Kernicterus (bilirubin encephalopathy)

Levels >25 mg/dL. Neurological syndrome caused by bilirubin depositing in brain cells

Apnea

Pause in respiration for more than 10-15 sec

How do you verify jaundice

Press cheek or abdomen w/ one finger

Birth trauma/injury type: Cranial, peripheral nerve

Radial nerve palsy

Laryngeal nerve palsy or excessive traction on neck

Weak hoarse cry

Surfactant is a phospholipid that assists in

alveoli expansion. - Surfactant keeps alveoli from collapsing and allows gas exchange to occur.