Chapter 34: Nursing Care of the High Risk Newborn

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect? A. Hypovolemia and/or shock B. Excessively cool environment C. Central nervous system (CNS) injury D. Pending renal failure

ANS: A Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities. Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to be delivered with respiratory distress.

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? A. Surfactant improves the ability of your babys lungs to exchange oxygen and carbon dioxide. B. The drug keeps your baby from requiring too much sedation. C. Surfactant is used to reduce episodes of periodic apnea.d. D. Your baby needs this medication to fight a possible respiratory tract infection.

ANS: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

What is the most important nursing action in preventing neonatal infection? A. Good handwashing B. Isolation of infected infants C. Separate gown technique D. Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

Which risk factors are associated with NEC? (Select all that apply.) A. Polycythemia B. Anemia C. Congenital heart disease D. Bronchopulmonary dysphasia E. Retinopathy

ANS: A, B, C Risk factors for NEC include asphyxia, RDS, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurses most appropriate action at this time? A. Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician B. Continuing to observe and making no changes until the saturations are 75% C. Continuing with the admission process to ensure that a thorough assessment is completed D. Notifying the parents that their infant is not doing well

ANS: A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determining fetal status.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetricians office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? A. Meconium aspiration, hypoglycemia, and dry, cracked skin B. Excessive vernix caseosa covering the skin, lethargy, and RDS C. Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat D. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is similar to that of a full-term baby. These infants are at increased risk for which conditions? (Select all that apply.) A. Problems with thermoregulation B. Cardiac distress C. Hyperbilirubinemia D. Sepsis E. Hyperglycemia

ANS: A, C, D Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is adequately feeding before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

NEC is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. Which intervention has the greatest effect on lowering the risk of NEC? A. Early enteral feedings B. Breastfeeding C. Exchange transfusion D. Prophylactic probiotics

ANS: B A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances the maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn disease, and celiac illness. The NICU nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement? A. Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). B. Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. C. Know that the greatest catch-up period is between 9 and 15 months postconceptual age. D. Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

With regard to infants who are SGA and intrauterine growth restriction (IUGR), the nurse should be aware of which information? A. In the first trimester, diseases or abnormalities result in asymmetric IUGR. B. Infants with asymmetric IUGR have the potential for normal growth and development. C. In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. D. Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; infants who are SGA have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with ineffective coping, related to? A. Severe immaturity B. Environmental stress C. Physiologic distress D. Behavioral responses

ANS: B Ineffective coping, related to environmental stress is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infants behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response.

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? A. NEC B. ROP C. BPD D. Intraventricular hemorrhage

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from the rupture of the fragile blood vessels in the ventricles of the brain and is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition? A. Hypertonia, tachycardia, and metabolic alkalosis B. Abdominal distention, temperature instability, and grossly bloody stools C. Hypertension, absence of apnea, and ruddy skin color D. Scaphoid abdomen, no residual with feedings, and increased urinary output

ANS: B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborns parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurses most appropriate action? A. Wait quietly at the newborns bedside until the parents come closer. B. Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn. C. Leave the parents at the bedside while they are visiting so that they have some privacy. D. Tell the parents only about the newborns physical condition and caution them to avoid touching their baby.

ANS: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infants condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infants appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? A. Rapid bolusing of the entire amount in 15 minutes B. Warm cloths to the abdomen for the first 10 minutes C. Slow, small, warm bolus feedings over 30 minutes D. Cold, medium bolus feedings over 20 minutes

ANS: C Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents? A. Infants stay in the NICU until they are ready to go home. B. Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. C. Parents of high-risk infants need special support and detailed contact information. D. If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

ANS: C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Simply because high-risk infants are eventually discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infants gestational age. Which statement regarding this intervention is most appropriate? A. Kangaroo care was adopted from classical British nursing traditions. B. This intervention helps infants with motor and CNS impairments. C. Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. D. This intervention gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parents bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

For clinical purposes, the most accurate definition of preterm and postterm infants is defined as what? A. Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) B. Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA C. Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth D. Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C Preterm and postterm are strictly measures of timebefore 37 weeks and beyond 42 weeks, respectivelyregardless of the size for gestational age.

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infants mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurses most appropriate response? A. Your baby will develop exactly like your first child. B. Your baby does not appear to have any problems at this time. C. Your baby will need to be corrected for prematurity. D. Your baby will need to be followed very closely.

ANS: C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infants responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress? a. Decreased respiratory rate b. Bradycardia, followed by an increased heart rate c. Mottled skin with acrocyanosis d. Increased physical activity

ANS: C The infant has minimal-to-no fat stores. During times of cold stress, the skin becomes mottled and acrocyanosis develops, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurses role is to observe the infant frequently to prevent heat loss and to respond quickly if signs and symptoms of cold stress occur. The respiratory rate increases, followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant who is experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, increased physical activity is the natural response to heat loss. However, in a term infant who is experiencing respiratory distress or in a preterm infant, physical activity is decreased.

An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia? A. 67 mm Hg B. 89 mm Hg C. 45 mm Hg D. 73 mm Hg

ANS: C The laboratory value of PaO2 of 45 mm Hg is below the range for a normal neonate and indicates hypoxia in this infant. The normal range for PaO2 is 60 to 80 mm Hg; therefore, PaO2 levels of 67 and 73 mm Hg fall within the normal range, and a PaO2 of 89 mm Hg is higher than the normal range.

Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing? A. Suffering from sleep or wakeful apnea B. Experiencing severe swings in blood pressure C. Trying to maintain a neutral thermal environment D. Breathing in a respiratory pattern common to premature infants

ANS: D Breathing in a respiratory pattern is called periodic breathing and is common to premature infants. This pattern may still require nursing intervention of oxygen and/or ventilation. Apnea is the cessation of respirations for 20 seconds or longer and should not be confused with periodic breathing.

Which clinical findings would alert the nurse that the neonate is expressing pain? A. Low-pitched crying; tachycardia; eyelids open wide B. Cry face; flaccid limbs; closed mouth c. High-pitched, shrill cry; withdrawal; change in heart rate d. Cry face; eyes squeezed; increase in blood pressure

ANS: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

When providing an infant with a gavage feeding, which infant assessment should be documented each time? A. Abdominal circumference after the feeding B. Heart rate and respirations before feeding C. Suck and swallow coordination D. Response to the feeding

ANS: D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infants response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infants response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infants response to the feeding, including the attempts to suck.

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide? A. Parents are not allowed to hold their infants who are dependent on oxygen. B. You may only hold your babys hand during the feeding. C. Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I dont think you should hold the baby. D. You may hold your baby during the feeding.

ANS: D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? A. Few blood vessels visible through the skin B. More subcutaneous fat C. Well-developed flexor muscles D. Greater surface area in proportion to weight

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

Because of the premature infants decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? A. Delayed growth and development B. Ineffective thermoregulation C. Ineffective infant feeding pattern D. Risk for infection

ANS: D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.