Chapter 13 Preterm and Postterm Newborns
What may first be done to stimulate breathing?
Gentle rubbing of the infant's feet, ankles, and back
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
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
Plasma glucose levels lower than 40 mg/dL indicate hypoglycemia in a term infant,
and in a preterm infant, lower than 30 mg/dL.
Pathological jaundice is more serious, occurs within 24 hours of birth,
and is secondary to an abnormal condition such as ABO-Rh incompatibility
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.
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
fibrous tissue to form behind the lens of each eye resulting in blindness and retinal detachment
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.
Early initiation of feeding reduce the risk of ?
hyopglycemia, hyperbiliribinemia and dehydration
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
Kangaroo care
is a method of care for preterm infants that uses skin-to-skin contact.
RDS type 1
is a result of lung immaturity, which leads to decreased gas exchange.
What is apnea in the pretterm newborn believed to be related to?
is believed to be related to immaturity of the nervous system.
Bronchopulmonary dysplasia
is the toxic response of the lung to oxygen therapy.
The goals of treatment for hyperbilirubinemia are to prevent
kernicterus which is 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
late term infant is one born between 41 weeks and 41 weeks, 6 days.
Extremely low birth weight
less than 1000 grams 2.2 lbs
Low birth weight
less than 2500 grams 5.5 lbs
preterm
less than 37 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.
Infants born to mothers who are diabetic or who have had
low vitamin D intake are also at risk for developing early hypocalcemia.
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
prothrombin a factor of the clotting mechanism.
Gestational age
refers to the actual time, from conception to birth, that the fetus remains in the uterus.
Postmaturity
refers to the infant showing characteristics of the postmature syndrome.
List three things that nurses observe for in a postterm infant.
respiratory distress usually because of aspiration of meconium-stained amniotic fluid, hypoglycemia , and hyperbilirubinemia
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
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
second year
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
The severely anemic infant may have
severe hypoxia yet not manifest clinical cyanosis.
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
Calcium is transported across the placenta throughout pregnancy, but in greater amounts during the
third trimester
What is the skin like in a preterm newborn?
transparent and loose.
For the preterm infant this is less than
37 weeks
The full term infant is one born between
39 and 40 weeks, 6 days
Term
39 to 40 weeks, 6 days
How many day after birth to breast fed infants show jaundice?
4 days
The postterm infant is born beyond
42 weeks
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
72 hours
What are the normal saturation levels
92% or above
A pulse oximeter saturation level of
92% or higher is normal
Set alarm switch to minimum acceptable oxygen saturation (Sao2) of approximately
92%-95%.
What are plasma glucose in preterm infant
< 30 mg/dl
What are plasma glucose in term infant
<40 mg/dl
Apnea is defined as the cessation of breathing for
20 seconds or longer.
What is the treatment for hypocalcemia?
Administering intravenous calcium gluconate
The following problems are associated with postmaturity:
•Asphyxia •Meconium aspiration: •Poor nutritional status•Increase in red blood cell production (polycythemia) •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:
•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:
•Tremors •Weak cry •Lethargy •Convulsions •Plasma glucose level lower than 40 mg/dL (term) or 30 mg/dL (preterm)
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
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
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
Treatment of sepsis is?
-administration of IV antibiotics - maintain warmth and nutrition - Close monitor VS - Cluster care to conserve energy - follow standard precautions
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
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
1 and 3 mL/kg/hr.
List four specific examples of immature body systems that puts preterm newborns at risk for developing sepsis.
1. The liver of the preterm infant is immature and forms antibodies poorly. 2. Body enzymes are inefficient. 3. There is little or no immunity received from the mother, and stores of nutrients, vitamins, and iron are insufficient.
The nurse records the temperature of the infant and the incubator every
2 hours.
In late-onset jaundice of the breastfed infant, the breast milk itself may inhibit conjugation of bilirubin, and therefore formula may be substituted for _
24 to 48 hours to reduce bilirubin levels.
The total serum bilirubin level typically peaks
3 to 5 days after birth.
If the infant is gavage fed, the tube is replaced every
3 to 7 days
The ability to coordinated breathing, sucking and swallowing develops at how many weeks?
34 weeks Depends on how well developed for feeding
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.
The ability to coordinate breathing, sucking, and swallowing does not develop before
34 weeks of gestation.
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
Necrotizing enterocolitis (NEC)
Acute inflammation of the bowel that leads to bowel necrosis
An early term infant is born between
An early term infant is born between 37 weeks and 38 weeks, 6 days.
One standardized method used to estimate gestational age within 1 to 2 weeks is the
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.
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 AKA weakness, tachypnea, grunt-like sounds, nasal flaring, cyanosis, intercostal and sternal retractions
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.
Very low birth weight
Less than 1500 grams 3.3 lbs
Cold stress increases the need for what two things?
Oxygen and glucose
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
The lower the gestational age
The higher the risk of RDS
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.
The infant's ability to absorb fats is poor
These include fat-soluable vitamins
Superficial veins may be seen beneath the
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.
Surfactant is high in lecithin, a fatty protein necessary for the
absorption of oxygen by the lungs
Gestational Age
actual time from conception to the birth that fetus 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.
low hypocalcemia usually occurs about
age 1 week in newborn or preterm infants who are fed cow's milk.
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 which stimulates the lungs to mature in 1 to 2 days and will last for 2 weeks
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
An increase of more than 5 mg/dL in 24 hours or a bilirubin level greater than 12.9 mg/dL requires
careful investigation
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
There must be at least 5g/dL of desaturated hemoglobin AKA unoxygenated blood to produce
clinical cyanosis.
What can alter surfactant production?
during cold stress hypoxia poor tissue profusion
Maintaining a sufficient level of vitamin E and avoiding
excessively high concentrations of oxygen may help to prevent this condition.
In early hypocalcemia the parathyroid
fails to respond to the preterm infant's low calcium levels.
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 abundant,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 and 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
Factors implicated for necrotizing enterocolitis (NEC) include a diminished blood supply to the lining of the bowel wall because of Hypoxia or sepsis
that causes a decrease in protective mucus and results in bacterial invasion of the delicate tissues.
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.
what is bronchopulmonary dysplasia?
toxic response of the lung to oxygen therapy
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)
