1. Nancy Pares, RN, MSN Metro Community College
NURS Unit 4
Nancy Pares, RN, MSN
Metro Community College

2. Objective 1
Discuss pathophysiology and nursing process for high risk newborn

3. Identification of At-risk Newborn
Low socioeconomic level of the mother
Limited or no prenatal care
Exposure to environmental dangers
Preexisting maternal conditions
Maternal factors such as age or parity
Medical conditions related to pregnancy
Pregnancy complications

4. Feeding Guidelines
Table 32–1 Suggested feeding guidelines for the preterm infant.

5. Early Feeding Skills (EFS)
Table 32–2 Examples of efs items within each section.

6. Preterm Infant: Respiratory Alterations
Inadequate surfactant production
Muscular coat of pulmonary blood vessels is not completely developed
Greater risk for the ductus arteriosis to remain open

7. Fetal/Neonatal Risk Factors for Resuscitation
Nonreassuring fetal heart rate pattern
Difficult birth
Fetal scalp/capillary blood sample-acidosis pH<7.20
Meconium in amniotic fluid
Prematurity
Macrosomia or SGA

8. Respiratory Distress Assessment
Table 33–1 Clinical assessments associated with respiratory distress.

9. Respiratory Distress Assessment
Table 33–1 (continued) Clinical assessments associated with respiratory distress.

10. Respiratory Distress Assessment
Table 33–2 Oxygen monitors.

11. Fetal/Neonatal Risk Factors for Resuscitation (continued)
Male infant
Significant intrapartum bleeding
Structural lung abnormality or oligohydramnios
Congenital heart disease
Maternal infection
Narcotic use in labor

12. Fetal/Neonatal Risk Factors for Resuscitation (continued)
An infant of a diabetic mother
Arrhythmias
Cardiomyopathy
Fetal anemia

13. Respiratory Distress Syndrome (RDS)
Deficiency or absence of surfactant
Atelectasis
Hypoxemia, hypercarbia, academia
May be due to prematurity or surfactant deficiency

14. Figure 33–5 RDS chest x-ray
Figure 33–5 RDS chest x-ray. Chest radiograph of respiratory distress syndrome characterized by a reticulogranular pattern with areas of microatelectasis of uniform opacity and air bronchograms. SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.

15. RDS: Nursing Care Maintain adequate respiratory status
Maintain adequate nutritional status
Maintain adequate hydration
Education and support of family

16. Figure 33–9 Premature infant under oxygen hood
Figure 33–9 Premature infant under oxygen hood. Infant is nested and has a nonnutritive sucking pacifier. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

17. Transient Tachypnea of the Newborn (TTN)
Failure to clear lung fluid, mucus, debris
Exhibit signs of distress shortly after birth
Symptoms
Expiratory grunting and nasal flaring
Subcostal retractions
Slight cyanosis

18. TTN: Nursing Care Maintain adequate respiratory status
Maintain adequate nutritional status
Maintain adequate hydration
Support and educate family

19. Meconium Aspiration Syndrome (MAS)
Mechanical obstruction of the airways
Chemical pneumonitis
Vasoconstriction of the pulmonary vessels
Inactivation of natural surfactant

20. MAS: Nursing Care Assess for complications related to MAS
Maintain adequate respiratory status
Maintain adequate nutritional status
Maintain adequate hydration

21. Persistent Pulmonary Hypertension (PPHN)
Blood shunted away from lungs
Increased pulmonary vascular resistance (PVR)
Primary
Pulmonary vascular changes before birth resulting in PVR
Secondary
Pulmonary vascular changes after birth resulting in PVR

22. PPHN: Nursing Care Minimize stimulation
Maintain adequate respiratory status
Observe for signs of pneumothorax
Maintain adequate nutritional status
Maintain adequate hydration status
Support and educate family

23. Figure 33–10 Chest x-ray of a left-sided pneumothorax
Figure 33–10 Chest x-ray of a left-sided pneumothorax. A rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung (air shows on x-ray as dark area over lung). SOURCE: Courtesy of Carol Harrigan, RNC, MSN, NNP.

24. Genetic disorders
This information will be discussed in greater detail later in the course.
For the purposes of this unit, know that certain disorders are genetic

25. Congenital Anomalies
Table 32–3 Congenital anomalies: identification and care in newborn period.

26. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

27. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

28. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

29. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

30. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

31. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

32. Congenital Anomalies
Table 32–3 (continued) Congenital anomalies: identification and care in newborn period.

33. Cardiac Defects
Table 32–7 Cardiac defects of the early newborn period.

34. Cardiac Defects
Table 32–7 (continued) Cardiac defects of the early newborn period.

35. Cardiac Defects
Table 32–7 (continued) Cardiac defects of the early newborn period.

36. Cardiac Defects
Table 32–7 (continued) Cardiac defects of the early newborn period.

37. Cardiac Defects
Table 32–7 (continued) Cardiac defects of the early newborn period.

38. Infants at Risk for HIV/AIDS
Table 32–6 Issues for caregivers of infants at risk for HIV/AIDS.

39. Infants Born to HIV/AIDS Infected Mothers: Consequences
Prematurity
SGA
Failure to thrive
Enlarged spleen and liver
Swollen glands

40. Infants Born to HIV/AIDS Infected Mothers: Consequences
Recurrent respiratory infection
Rhinorrhea
Recurrent GI problems
Persistent or recurrent candidiasis

41. Nursing Care of the Infant Born to HIV/AIDS Infected Mothers
Provide comfort
Keep the newborn well nourished
Keep the infant protected from infections
Facilitate growth, development, and attachment

42. Sepsis
Risk factors
Maternal infection (group B streptococcus most common)
Long labor, prolonged rupture of the membranes
Maternal fever, chorioamnionitis
Fetal distress, aspiration

43. Sepsis (continued) Assessment findings Management
Unstable temperature, poor tone, poor sucking
Management
Antibiotics
Supportive care

44. Signs and Symptoms of Sepsis
Lethargy or irritability
Hypotonia
Hypotension
Pallor, duskiness, or cyanosis
Cool and clammy skin

45. Signs and Symptoms of Sepsis (continued)
Temperature instability
Feeding intolerance
Hyperbilirubinemia
Tachycardia followed by apnea/bradycardia

46. Symptoms of Syphilis Rhinitis Red rash around the mouth and anus
Irritability
Generalized edema and hepatosplenomegaly
Congenital cataracts
SGA and failure to thrive

47. Syphilis: Nursing Management
Initiate isolation
Administer penicillin
Provide emotional support for the family

48. Gonorrhea Symptoms Nursing management Conjunctivitis
Corneal ulcerations
Nursing management
Administration of ophthalmic antibiotic ointment
Referral for follow-up

49. Symptoms of Herpes
Small cluster vesicular skin lesions over the entire body
DIC
Pneumonia
Hepatitis
Hepatosplenomegaly
Neurologic abnormalities

50. Herpes: Nursing Management
Careful hand washing and gown and glove isolation
Administration of IV vidarabine or acyclovir
Initiation of follow-up referral
Support and education of parents

51. Chlamydia Symptoms Nursing management Pneumonia Conjunctivitis
Administration of ophthalmic antibiotic ointment
Referral for follow-up

52. Maternally Transmitted Infections
Table 33–6 Maternally transmitted newborn infections.

53. Maternally Transmitted Infections
Table 33–6 (continued) Maternally transmitted newborn infections.

54. Antibiotic/antiviral Therapy
Table 33–7 Neonatal sepsis antibiotic/antiviral therapy.

55. Nursing Care of the Drug-Exposed Newborn
Neonatal abstinence scoring
Monitoring VS and pulse oximetry until stable
Small frequent feedings
IV therapy if needed
Positioning on the right side-lying or semi- Fowler’s
Monitoring frequency of diarrhea and vomiting

56. Nursing Care of the Drug-Exposed Newborn
Weigh infant every 8 hours during withdrawal
Swaddle infant
Protect face and extremities from excoriation
Place infant in quiet, dimly lighted area of the nursery
Administration of medications

57. Newborn Withdrawal
Table 32–4 Clinical manifestations of newborn withdrawal.

58. Neonatal Abstinence
Table 32–5 Neonatal abstinence score sheet.

59. Neonatal Abstinence
Table 32–5 (continued) Neonatal abstinence score sheet.

60. Figure 33–14 Potential sites for heel sticks
Figure 33–14 Potential sites for heel sticks. Avoid shaded areas to prevent injury to arteries and nerves in the foot and the important longitudinally oriented fat pad of the heel, which in later years could impede walking.

61. Figure 33–15 Heel stick. With a quick, piercing motion, puncture the lateral heel with a microlance. Be careful not to puncture too deeply.

62. Postmaturity Syndrome
Hypoglycemia
Meconium aspiration and oligohydramnios
Polycythemia
Congenital anomalies
Seizures
Cold stress

63. Care of the Premature Infant
Delivery prior to 37 weeks’ gestation
Factors
Multiple gestation, PROM, incompetent cervix

64. Assessment of the Preterm Newborn
Physical characteristics
Gestational age
Maternal prenatal risk factors
Delivery risk factors
Physical assessment
Family assessment

65. The Premature Infant (continued)
Assessment
Gestational age assessment
Neurologic assessment
Physical characteristics
Thin skin, soft cartilage, absent plantar creases
Abundant lanugo and vernix
Genitalia characteristic of prematurity

66. Review of Systems and Potential Complications
Cardiovascular
Patent ductus arteriosis
Hypotension
Central nervous system
Intraventricular hemorrhage
Posthemorrhagic hydrocephalus
Hematologic system
Anemia
Polycythemia
Hepatic system
Hyperbilirubinemia
Phototherapy

67. Review of Systems (continued)
Gastrointestinal system
Dysmotility
Necrotizing enterocolitis
Gastroesophageal reflux
Immune system
Infection
Integumentary system
Epidermal stripping
Absorption of chemical agents
Crib with head elevated for reflux

68. Review of Systems (continued)
Ophthalmologic system
Retinopathy of prematurity
Renal system
Oliguria
Glycosuria
Respiratory system
Respiratory distress syndrome
Bronchopulmonary dysplasia
Apnea of prematurity
Pneumonia
Preterm infant in
an oxygen hood

69. Preterm Infant: GI Alterations
Poorly developed gag reflex
Incompetent esophageal cardiac sphincter
Poor sucking and swallowing reflexes
Difficulty meeting caloric needs for growth
Inability to handle the increased osmolarity of formula protein
Difficulty with absorbing saturated fats

70. Preterm Infant: GI Alterations (continued)
Difficulty with lactose digestion
Deficiency of calcium and phosphorous
Increased basal metabolic rate and increased oxygen requirements
Feeding intolerance
Potential for the development of necrotizing enterocolitis (NEC)

71. Preterm Infant: Alterations in Thermogenesis
Unavailability of glycogen and brown fat
Inability to increase oxygen consumption
High ratio of body surface area to body weight
Extended position increases body surface area
Decreased ability to vasoconstrict superficial blood vessels

72. Preterm Infant: Kidney Alterations
Lower glomerular filtration rate (GFR)
Limited ability to concentrate urine or excrete large amounts of fluid
Excrete glucose at a lower serum glucose level
Buffering capacity is reduced
Excretion time of drugs is longer

73. Preterm Infants: Liver Alterations
Glycogen stores are used rapidly
Glycogen stores are affected by asphyxia and cold stress
Low iron stores
Conjugation is impaired

74. Preterm Infants: Other Alterations
Immunologic
Lack of passive IgG antibodies
Skin is easily excoriated
Neurologic
Increased risk for IVH & ICH
Delayed or absent reactivity

75. Hydrocephalus: Nursing Assessments
Occipital-frontal baseline measurements
Daily head circumferences
Skin integrity
Signs and symptoms of infection
Signs of widening of suture lines

76. Hydrocephalus: Nursing Interventions
Assist with head ultrasounds and transillumination
Change position frequently
Clean skin creases
Keeping a sheepskin under the head
Postoperatively position head off the operative site

77. Intrauterine growth restriction
Small for gestational age
Large for gestational age
Post term infant

78. Intrauterine Growth Restriction
Infants <10th percentile for weight at birth
May be symmetric or asymmetric
Factors may be fetal, maternal, or placental
Complications
Hypoxia, hypothermia, hypoglycemia, polycythemia, hyperbilirubinemia, meconium aspiration

79. Intrauterine Growth Restriction (continued)
Nursing implications
Prevent heat loss
Monitor blood glucose, feed early
Monitor for respiratory complications
Management of hyperbilirubinemia

80. Small-for-gestational-age
Maternal factors
Maternal disease
Environmental factors
Placental factors
Fetal factors

81. Triplets Manifesting Different Rates of Growth

82. Large for Gestational Age Infant
Infants >90th percentile for weight at birth
Factors
Maternal diabetes, parental obesity
Complications
Difficult delivery, birth trauma, hypoglycemia
Nursing implications
Assess for birth injury
Monitor for hypoglycemia

83. Impact of Maternal Diabetes Mellitus (DM) on the Newborn
LGA
SGA
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia

84. Impact of Maternal Diabetes Mellitus (DM) on the Newborn
Birth trauma
Polycythemia
RDS
Congenital malformations

85. Infants of Diabetic Mothers
Risk factors
Congenital anomalies
Macrosomia (>4,000 gm)
Hypoglycemia
Respiratory distress syndrome

86. Infants of Diabetic Mothers (continued)
Prevention of complications
Normoglycemia during gestation and labor
Deliver when lungs are mature
Prepare for delivery of large infant
Monitor for hypoglycemia

87. Hypoglycemia Symptoms
Lethargy or jitteriness
Poor feeding and sucking
Vomiting
Hypothermia and pallor
Hypotonia, tremors
Seizure activity, high pitched cry, exaggerated moro reflex

88. Hypoglycemia: Nursing Care
Routine screening for all at risk infants
Early feedings
D10W infusion

89. Risk Factors for Hyperbilirubinemia
Table 33–3 Risk factors for development of severe hyperbilirubinemia in infants of 35 or more weeks’ gestation (in approximate order of importance).

90. Lab Evaluation of Jaundice
Table 33–4 Laboratory evaluation of the jaundiced infant of 35 or more weeks’ gestation.

91. Checklist for in-room Phototherapy
Table 33–5 Instructional checklist for in-room phototherapy.

92. Hyperbilirubinemia Excess bilirubin in the blood resulting in jaundice
Can be caused by physiologic or pathologic processes
Normal RBC breakdown
Rh or ABO incompatibility

93. Hyperbilirubinemia (continued)
Complications
Kernicterus
Erythroblastosis fetalis
Hydrops fetalis
Assessment findings
Jaundice, elevated bilirubin levels

94. Management of Hyperbilirubinemia
Encourage frequent feedings
Exposure to sunlight
Phototherapy
Shield infant’s eyes
Monitor body temperature
Monitor weight
Monitor fluid intake
Weigh diapers
Note frequency of stools

95. Physiologic Hyperbilirubinemia
Appears after first 24 hours of life
Disappears within 14 days
Due to an increase in red cell mass

96. Pathologic Hyperbilirubinemia
Appears within first 24 hours of life
Serum bilirubin concentration rises by more than 0.2 mg/dL per hour
Bilirubin concentrations exceed the 95th percentile
Conjugated bilirubin concentrations are greater than 2 mg/dL
Clinical jaundice persists for more than 2 weeks in a term newborn

97. Causes of Pathologic Hyperbilirubinemia
Hemolytic disease of the newborn
Erythroblastosis fetalis
Hydrops fetalis
ABO incompatibility

98. Treatment of Pathologic Hyperbilirubinemia
Resolving anemia
Removing maternal antibodies and sensitized erythrocytes
Increasing serum albumin levels
Reducing serum bilirubin levels
Minimizing the consequences of hyperbilirubinemia

99. Phototherapy: Nursing Care
Maximize exposure of the skin surface to the light
Periodic assessment of serum bilirubin levels
Protect the newborn’s eyes with patches
Measure irradiance levels with a photometer
Good skin care and reposition infant at least every 2 hours
Maintain an NTE and adequate hydration and nutrition

100. Figure 33–18 Infant receiving phototherapy
Figure 33–18 Infant receiving phototherapy. The phototherapy light is positioned over the incubator. Bilateral eye patches are always used during photo light therapy to protect the baby’s eyes. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.

101. Nutrition and Fluid Management
Fluids
Strict I&O, weigh diapers
Electrolyte management
Management of sodium and potassium levels
Glucose homeostasis
Feeding
Gavage or nipple method
Types: formula or breast milk
Gavage feeding tube

102. Developmental Care of the Preterm Infant
Light
Sound
Temperature
Positioning and containment strategies
Handling and touching
Nonnutritive sucking

103. Cold Stress Increase in oxygen requirements
Increase in utilization of glucose
Acids are released in the bloodstream
Surfactant production decreases

104. Figure 33–13 Cold stress chain of events
Figure 33–13 Cold stress chain of events. The hypothermic, or cold-stressed, newborn attempts to compensate by conserving heat and increasing heat production. These physiologic compensatory mechanisms initiate a series of metabolic events that result in hypoxemia and altered surfactant production, metabolic acidosis, hypoglycemia, and hyperbilirubinemia.

105. Cold Stress: Nursing Care
Observe for signs of cold stress
Maintain NTE
Warm baby slowly
Frequent monitoring of skin temperature
Warming IV fluids
Treat accompanying hypoglycemia

106. Objective 2
Explain the assessment and nursing interventions associated with birth injuries

107. Trauma and Birth Injuries
Fractures
Clavicle, long bones, skull most common
Risks
Large infant, breech, difficult labor
Assessment
Impaired mobility
Management
Immobilization, traction, casting

108. Trauma and Birth Injuries (continued)
Facial Palsy
Usually related to use of forceps
Brachial Palsy
Usually related to difficult delivery such as shoulder dystocia
Assessment
Impaired mobility of arm
Paralysis may be temporary or permanent

109. Needs of Parents of At-risk Infants
Realistically perceiving the infant’s medical condition and needs
Adapting to the infant’s hospital environment
Assuming primary caretaking role
Assuming total responsibility for the infant upon discharge
Possibly coping with the death of the infant if it occurs

110. Facilitating Parental Attachment
Facilitating family visits
Allowing the family to hold and touch the baby
Giving the family a picture of the baby
Liberal visiting hours
Encouraging the family to get involved in the care

111. Figure 33–20 Mother of a 26 weeks’ gestational age infant with respiratory distress syndrome on a ventilator is getting acquainted with her baby. Physical contact is vital to the bonding process and should be encouraged whenever possible. SOURCE: Courtesy of Lisa Smith-Pedersen, RNC, MSN, NNP.