1. Caring for the Newborn at Risk
Chapter 19
Caring for the Newborn at Risk
Refer to table 19-1 & Box 19-1

2. Risk Factors for Newborns
Intrauterine development
Intrapartum development
Extrauterine development

3. A & P Review
Lung maturity
Circulatory maturity
Neurological maturity

4. Classification of High-Risk Newborns
Gestational Age (GA)
Preterm (born before 37 weeks)
Term (born between 38 and 42 weeks)
Postterm (born after 42 weeks)
Refer to Box 19-2 for viability

5. Classification of High-Risk Newborns
Birth Weight
Low birth weight (LBW) (<2500 g)
Very low birth weight (VLBW) (<1500 g)
Extremely low birth weight (ELBW) (<1000 g)
Refer to Table 19-2

6. Intrauterine Growth Restriction (IGUR)
A term used to denote a lack of intrauterine fetal growth that usually results in an SGA newborn
Refer to Box 19-3 for conditions causing SGA

7. Small-for-Gestational-Age Infants (SGA)
Infants born at any gestational age who have a birth weight that falls below the 10th percentile on the growth charts

8. Conditions Affecting the SGA Newborn
Hypothermia
Pain
Hypoglycemia
Polycythemia
Refer to Figures 19-3 & 19-4 for pain assessment

9. Large-for-Gestational- Age Infants (LGA)
Infants born who are over the 90th percentile on the growth chart
Refer to Boxes 19-5 & 19-6

10. Conditions Affecting LGA Newborn
Chronic hyperglycemic state
Transient tachypnea of the newborn
Hypoglycemia
Hypocalcemia
Hypomagnesemia
Birth injuries
Brachial plexus injuries
Fractures
Refer to Figure 19-6 & Table 19-3

11. The Premature Newborn Severe prematurity Moderate prematurity
23 to 26 weeks
Moderate prematurity
26 to 30 weeks
Refer to Table 19-4 for physical assessment

12. Physical Assessment of the Premature Newborn
Skin
Head
Chest
Cardiac
Abdomen
Musculoskeletal
Genitalia
Neurological/sensory

13. Conditions Affecting the Premature Newborn

14. Respiratory Distress Syndrome (RDS)
Atelectasis with congestion and edema in lung spaces
Lecithin-sphingomyelin (L/S) ratio and phosphatidylglycerol (PG) levels low
Underdeveloped alveoli
Signs and symptoms begin shortly after birth
Nursing Care:
Provide oxygenation
Maintain mechanical ventilation
Assist with endotracheal intubation (ET)
Administer syntheic surfactant via ET
Wean ASAP to prevent complications

15. Apnea of Prematurity
Apnea >15 to 20 seconds accompanied by pallor, hypotonia, cyanosis, and bradycardia
Nursing Care:
Monitor cardiorespiratory (C-R) status
Apply continuous pulse oximeter
Watch for A and B spell

16. Jaundice
Diagnosed in term infants with a serum bilirubin level >12.9 mg/dL and in preterm infants >15mg/dL
Nursing Care:
Based on underlying cause
Give phototherapy
Ensure hydration (electrolyte solution)
Complications:
Bilirubin encephalopathy
Kernicterus

17. Retinopathy of Prematurity
Result of immature retinal vasculature followed by hypoxia
Inversely related to gestational age
Risk factors
Diagnosis –– 5 stages
Nursing Care:
Fluctuations in concentrations of oxygen must be prevented
Wean off oxygen ASAP
Decrease constant bright lights
Encourage routine examinations

18. Sudden Infant Death Syndrome (SIDS)
Anemia of prematurity
Hemoglobin below 35% and 45%
Nursing Care:
Administer recombinant human erythropoieten SC
Sudden Infant Death Syndrome (SIDS)
“Back to Sleep”
Educate parents about prevention

19. The Post term Newborn
Newborns in utero after the optimal growth time (42 weeks)
Skin is parchment-like
Fingers are long and peeling
Muscle wasting is present

20. Conditions Affecting the Postterm Newborn
Meconium Aspiration Pneumonia — meconium aspirated at birth
Meconium-stained skin, nails, and umbilical cord
Initial respiratory distress
Rales and rhonchi on auscultation
Nursing Care:
Give chest physiotherapy (CPT)
Monitor mechanical ventilation
Administer medications

21. Persistent Pulmonary Hypertension of the Newborn
Vascular resistance in pulmonary system
Meconium-stained amniotic fluid
Brief respiratory distress at birth, then resolves and returns about 12 hours later
Centrally cyanotic and tachypenic
Audible murmur
Nursing Care:
Extracorporeal membrane oxygenation (ECMO)
See Chapter 19 Nursing Care Plan
Refer to Figure 19-11
Refer to Care Plan in chapter for detailed Nursing care

22. Additional Conditions Affecting the High-Risk Newborn
Metabolic conditions
Neurologic conditions
Gastrointestinal conditions
Infections

23. Metabolic Conditions Phenylketonuria (PKU) Galactosemia
Phenylalanine-free diet, elimination of protein
Galactosemia
Galactose-free diet
Maple Syrup Urine Disease
Low-protein diet, thiamine supplements
Refer to Box 19-7 for newborn screening tests

24. Metabolic Conditions Homocystinuria Biotinidase Deficiency
Diet therapy ― high doses vitamin B6
Methionine and cystine restriction
Biotinidase Deficiency
Pantothenic acid or biotin (types of B vitamins)

25. Neurological Conditions
Intraventricular and Periventricular Hemorrhage [categorized by extent and involvement (grades)]
Nursing Care:
Recognize seizures
Administer antiseizure medications
Prevent cerebral damage
Maintain adequate oxygenation
Educate parents

26. Neurological Conditions
Anencephaly (skull and cerebrum are malformed)
Encephalocele (protrusion of brain through a skull defect)
Microcephaly (smaller than normal head circumference)
Holoprosencephaly (cerebral matter fails to form as two distinct hemispheres)

27. Gastrointestinal Conditions
Cleft Lip and Palate ― has genetic and environmental predispositions
Nursing Care:
Provide adequate nutrition
Feed in upright position
Surgery: CL ― 3 months, CP ― before 18 months
Educate and provide emotional support for parents

28. Gastrointestinal Conditions
Necrotizing Enterocolitis
Ischemic episode of the bowel; can produce septicemia
Nursing Care:
Ensure that oral feedings are stopped
Discuss possible surgery

29. Abdominal Wall Defects
Gastroschisis and Omphalocele
Nursing Care:
Surgery within 2 to 4 hours
Cover abdominal contents with moist gauze and wrap in plastic
Position carefully
Place NG/OG
IVF at 1.5 times normal maintenance
Postoperative care focuses on fluids, electrolyte balance, nutritional support, infection protection, pain management, and keeping parents informed
Refer to Figure for gastroschisis

30. Infections in the Newborn
Herpes Simplex
HSV-1 acquired from people with herpes lesions of the mouth
HSV-2 acquired through a genital infection
Nursing Care:
Acyclovir (Avirax)
Ensure proper developmental stimulation
Neonatal Sepsis
Systemic infection
Review diagnostic workup
Give antibiotics for a minimum of 48 hours
Refer to Table 19-5 for common causes of neonatal sepsis

31. Developmental Delay Neonatal Abstinence Syndrome (NAS) Nursing Care:
Drug-abusing mother
Irritability
Nursing Care:
Laboratory tests done to reveal if drugs are in the newborn’s system
Use neonatal abstinence scoring tool every 3 hours
Refer to Table 19-6 for drugs that cause withdrawal symptoms
Refer to Box 19-8 for signs of neonatal abstinence syndrome
Refer to Box 19-9 for medications used to treat IDAM

32. Care of the High-Risk Newborn
Blood Pressure
Nutritional Care
Developmental Care
Noise
Lighting
Handling
Positioning

33. Neonatal Intensive Care Unit
Educate parents on what to expect, rules of the unit, and expectations
Create partnership with parents
Encourage touch
Provide discharge planning

34. Classification of the Neonatal Intensive Care Unit
Level I ― provides well newborn care and stabilization of high-risk newborns
Level II ― provides premature care (give oxygen and intravenous therapy given)
Level III ― provides care to ventilate newborns

35. Transporting the Preterm Newborn
Transport is done if more technologically advanced care is needed
Transport team comprised of professionals
STABLE program
Home Work#3: ATI Practice test A & B
Refer to Box for STABLE program