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.