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MCN 2 > 10 NURSING CARE OF HIGH RISK NEWBORN > Flashcards

10 NURSING CARE OF HIGH RISK NEWBORN Flashcards

1
Q

Newborn Priorities

A
  1. Initiation & Maintenance of Respirations
  2. Establishment of Extrauterine Circulation
  3. Maintenance of Fluid & Electrolyte Balance
  4. Control of Body Temperature
  5. Establish Adequate Nutritional Intake
  6. Establishment of Waste Elimination
  7. Prevention of Infection
  8. Establishment of Infant - Parent Relationship
  9. Developmental Needs
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2
Q

A live born infant born before the end of week 37 gestation

A

Preterm Infant

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3
Q

Born between 34 and 37 weeks

A

Late Preterm

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4
Q

Born between 24 and 34 weeks

A

Early Preterm

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5
Q

Common Factors Associated with Preterm Birth

A

● Low socioeconomic level
● Poor nutritional status
● Lack of prenatal care
● Multiple pregnancy
● Previous early birth
● Race
● Cigarette smoking
● Age of the mother (younger than age 20)
● Order of birth
● Closely spaced pregnancies
● Abnormalities of the mother’s reproductive system, such as intrauterine septum
● Infections (UTI)
● Obstetric complications, such as premature rupture of membranes or premature separation of the placenta
● Early induction of labor
● Elective cesarean birth

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6
Q

Disproportionately large (> 3cm greater than
chest size)

A

Head

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7
Q

Small

A

Fontanelles

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8
Q

Small, hazy vitreous humor, myopia

A

Eyes

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9
Q

Large, immature cartilage, pinna falls forward

A

Ears

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10
Q

Ruddy; vernix caseosa, lanugo, few or (-) creases on soles of feet

A

Skin

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11
Q

(-) sucking, swallowing and breathing
reflexes, diminished Achilles tendon reflex; less active and rarely cries

A

Neurologic

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12
Q

Potential Complications of Preterm Infant

A

● Anemia of Prematurity
● Acute Bilirubin Encephalopathy
● Periventricular/Intraventricular Hemorrhage
● Retinopathy of Prematurity

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13
Q

Occurs from a combination of immaturity of
the hematopoietic system combined with the
destruction of RBCs because of low levels of Vitamin E, a substance that normally protects RBCs against oxidation.

A

Anemia of Prematurity

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14
Q

The infant will appear pale and may be lethargic and anorectic.

A

Anemia of Prematurity

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15
Q

Excessive blood drawing for electrolyte or blood gas analysis can potentiate the problem.

A

Anemia of Prematurity

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16
Q

This is the destruction of brain cells by invasion of indirect or unconjugated bilirubin.

A

Acute Bilirubin Encephalopathy

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17
Q

Also be called “Kernicterus”

A

Acute Bilirubin Encephalopathy

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18
Q

Tissue surrounding the ventricles

A

Periventricular hemorrhage

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19
Q

Bleeding into the ventricles

A

Intraventricular hemorrhage

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20
Q

It is an acquired ocular disease that leads to partial or total blindness in children, caused by vasoconstriction of immature retinal blood vessels with high concentration of oxygen as the causative agent

A

Retinopathy of Prematurity

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21
Q

Provide early screening and detection in infants: <___ weeks of gestation and weight <___ g
(3.3 pounds).

A

30, 1500

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22
Q

Decrease exposure preterm infant to ___, ___

A

bright, direct lighting

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23
Q

Use supplemental ___ judiciously and monitor ___ blood levels carefully

A

oxygen

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24
Q

Surgical repair of detached retina.

A

Laser photocoagulation

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25
Q

Anti vascular endothelial growth factor drug

A

Avastin (bevacizumab)

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26
Q

Nursing Diagnosis for Preterm Infant

A

● Impaired gas exchange related to immature
pulmonary functioning
● Risk for deficient fluid volume related to insensible water loss at birth and small stomach capacity
● Risk for imbalanced nutrition, less than body
requirements, related to additional nutrients needed for maintenance of rapid growth, possible sucking difficulty, and small stomach
● Ineffective thermoregulation related to immaturity
● Risk for infection related to immature immune
defenses in the preterm infant
● Risk for impaired parenting related to interference with parent-infant attachment resulting from hospitalization of infant at birth

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27
Q

Nursing Management for Preterm Infant

A

● Keep the infant warm during resuscitation
● Carryout all procedures gently
● Intravenous fluid should be given via a continuous infusion pump
● Intravenous sites must be checked conscientiously
● Monitor the baby’s weight, urine output and specific gravity, and serum electrolytes.
● Measure urine output by weighing diapers
● Schedule Feeding
● Be certain that a radiant heat warmer is warmed
● Linen and equipment used with preterm infants must not be shared with other infants.
● Allow the mother to feed her infant with supervision
● Encourage parents to begin interacting with their infant in as normal a manner as possible

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28
Q

Birth weight is below 10th percentile

A

The Small for Gestational Age Infant “Microsomia”

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29
Q

Common Factors Associated with SGA

A

● Nutrition
● Age of the Mother (Adolescent)
● Chromosomal abnormality
● Intrauterine infection
● Placental issues
● Diabetes mellitus
● Gestational hypertension
● Smoking

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30
Q

Appearance of SGA

A

● Below average weight, length and head circumference
● Poor Skin turgor
● Skull sutures widely separated
● Dull and lusterless hair
● Small Liver
● Sunken abdomen
● Dry umbilical cord

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31
Q

Laboratory Findings of SGA

A

● High hematocrit
● Increase RBCs (polycythemia)
● Hyperbilirubinemia
● Hypoglycemia

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32
Q

Nursing Diagnosis for SGA

A

● Ineffective breathing pattern related to
underdeveloped body systems at birth
● Risk for ineffective thermoregulation related to lack of subcutaneous fat
● Risk for impaired parenting related to child’s high-risk status and possible cognitive or neurologic impairment from lack of nutrients in utero

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33
Q

Nursing Management for SGA

A
  1. Closely observe both respiratory rate and character in the first few hours of life.
  2. Careful control of environment is essential to keep the infant’s body temperature in a neutral zone
  3. Encourage parents to provide toys suitable for their child’s chronological age
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34
Q

Birth weight is above the 90th percentile

A

The Large for Gestational Age Infant “Macrosomia”

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35
Q

Common Factors Associated with LGA

A

● Overproduction of nutrients & growth hormones
● Obesity
● Diabetes mellitus
● Multiparity
● Beckwith-Wiedemann syndrome

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36
Q

Appearance of LGA

A

● Immature reflexes
● Poor Apgar Score
● Extensive bruising
● Birth injury (broken clavicle or Erb-Duchenne
paralysis)
● Caput succedaneum, cephalohematoma, or molding

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37
Q

Assessment Criteria for LGA: Skin color for ___, ___, ___

A

ecchymosis, jaundice, and erythema

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38
Q

Assessment Criteria for LGA: Motion of extremities on spontaneous movement and
in response to a _____ to detect clavicle
fracture

A

Moro’s reflex

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39
Q

Assessment Criteria for LGA: Asymmetry of the _____ or unilateral lack of movement

A

anterior chest

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40
Q

Assessment Criteria for LGA: Eyes for evidence of unresponsive or dilated pupils; vomiting, bulging fontanelles, and a high-pitched cry suggestive of _____

A

increased intracranial pressure

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41
Q

Assessment Criteria for LGA: Activities such as jitteriness, lethargy, and uncoordinated eye movements that suggest _____

A

seizure activity

42
Q

Nursing Diagnosis for LGA

A

● Ineffective breathing pattern related to possible birth
trauma in the LGA newborn
● Risk for imbalanced nutrition less than body
requirements, related to additional nutrients needed to
maintain weight and prevent hypoglycemia

43
Q

Nursing Management for LGA

A
  1. Careful observation
  2. Offer both the mother and baby feeding support.
  3. Encourage parents to treat their baby as a fragile newborn who needs warm nurturing not as a tough big infant who has grown past that stage.
44
Q

Born after 41st week of a pregnancy

A

Post Term Infant

45
Q

Appearance of Post Term Infant

A

● Dry, cracked, almost leather like skin
● (-) Vernix
● SGA
● Less amniotic fluid
● Meconium stained
● Fingernails will have grown well
● Alert like 2 week old baby

46
Q

Common Factors Associated with Post Term Infant

A

● DOB
● Polycythemia
● Increase Hematocrit
● Hypoglycemia
● Decrease Subcutaneous fat levels

47
Q

Therapeutic Management for Post Term

A

● Sonogram
● Non-Stress Test/EFM

48
Q

Nursing Management for Post Term

A
  1. Make sure a woman spends enough time with her newborn
  2. Control possible hypoglycemia/meconium aspiration
  3. Educate mother on the importance of follow up care
49
Q

Occurs when a fetus has been subjected to asphyxia or other intrauterine stress that
causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid

A

Meconium Aspiration Syndrome

50
Q

Assessment of Meconium Aspiration Syndrome

A

● Difficulty establishing respiration
● Low Apgar score
● Tachypnea
● Retractions
● Cyanosis
● Barrel chest
● Poor gas exchange
● Bilateral coarse infiltrates

51
Q

Therapeutic Management for Meconium Aspiration Syndrome

A

● Amnioinfusion - dilute the amount of meconium in amniotic fluid
● C-Section
● Antibiotic Therapy
● Surfactant
● Oxygen & Assisted Ventilation

52
Q

Nursing Management for Meconium Aspiration Syndrome

A

● Observe infant closely for signs of trapping air in the alveoli
● Observe infant closely for signs of heart failure
● Maintain a temperature-neutral environment
● Perform chest physiotherapy with percussion and vibration

53
Q

Hyaline membrane disease is most often in newborns who are born prematurely

A

Respiratory Distress Syndrome (RDS)

54
Q

Compounds that lower the surface tension (or
interfacial tension) between two liquids, between a gas and a liquid, or between a liquid and a solid.

A

Surfactant

55
Q

Assessment for RDS

A

● Low body temperature
● Nasal Flaring
● Sternal and subcostal retractions
● Tachypnea (>60bpm)
● Cyanosis
● Seesaw respiration
● Heart failure (decreased urine output and edema)
● Pale gray skin
● Periods of apnea
● Bradycardia
● Pneumothorax

56
Q

Diagnosis for RDS

A

Chest Xray
Blood Gas

57
Q

Therapeutic Management for RDS

A

Surfactant replacement
Oxygen administration
Ventilation
Nitric Oxide
Extracorporeal Membrane Oxygenation (ECMO)
Supportive Care

58
Q

Surfactant: _____ infant before administration

A

Suction

59
Q

Surfactant: Assess infant’s RR, rhythm, O2 saturation and color before _____.

A

administration

60
Q

Surfactant: Ensure proper ___ placement before dosing

A

ET

61
Q

Surfactant: Change infant’s position during administration to encourage the drug to flow on both _____.

A

Lungs

62
Q

Surfactant: Assess infant’s RR, color, and pulse oximetry or ___ after administration.

A

ABG

63
Q

Surfactant: Do not suction ET for _____ after administration.

A

1 hour

64
Q

Prevention of RDS

A

● Magnesium Sulfate
● Betamethasone Sodium Phosphate and
Betamethasone Acetate

65
Q

A cessation in respirations lasting longer than 20 seconds, accompanied by bradycardia and/or cyanosis

A

Apnea

66
Q

Nursing Management of Apnea

A

● Flicking the soles of the foot
● Suction gently and only when needed
● Maintain a neutral thermal environment
● Indwelling NGTs
● Observe post feeding of infant
● Caffeine
● No to rectal temperature taking

67
Q

Rapid rate of respirations, up to 80 breaths/min.

A

Transient Tachypnea of the Newborn (TTN)

68
Q

Assessment for TTN

A

● Rapid breathing
● Mild retractions
● Nasal flaring
● Fluid in the lungs
● Respiratory acidosis
● Hypercapnia
● Hypoxemia

69
Q

Therapeutic Management for TTN

A

Oxygen Administration

70
Q

Excessive destruction of red blood cells, which leads to elevated bilirubin levels

A

Hemolytic Disease of the Newborn
(Hyperbilirubinemia)

71
Q

The major causes of increased erythrocyte destruction are ___ and ___ incompatibility.

A

Rh and ABO

72
Q

The mother’s blood type is Rh negative and the fetal blood type is Rh positive, this introduction of fetal blood causes sensitization to occur and the woman begins to form antibodies against the specific antigen.

A

Rh Incompatibility

73
Q

The maternal blood type is “O” and the fetal blood type is either “A or B” type blood. Hemolysis can become a problem with a first pregnancy.

A

ABO incompatibility

74
Q

O is incompatible with

A

A or B

75
Q

B is incompatible with

A

A or AB

76
Q

A is incompatible with

A

B or AB

77
Q

Assessment for Hemolytic Disease of the Newborn

A

● Anemia
● Jaundice (1st 24H)
● Hyperbilirubinemia
● Hypoglycemia

78
Q

Diagnostic Evaluation for Hemolytic Disease of the Newborn

A

● Coomb’s Test (Direct or Indirect)
● Percutaneous Umbilical Blood Sampling (PUBS)
● Amniocentesis

79
Q

Therapeutic Management for Hemolytic Disease of the Newborn

A

● Early feeding - Phototherapy
● Exchange Transfusion - Blood Transfusion
● Erythropoietin

80
Q

Phototherapy: Infant’s eyes must always be covered while under _____ lights

A

bilirubin

81
Q

Phototherapy: Commercial phototherapy mask or eye coverings must be used at _____ times.

A

all

82
Q

Phototherapy: Stools are often _____

A

Bright green

83
Q

Phototherapy: Urine may be _____

A

dark colored

84
Q

Exchange Transfusion: It should be done under a _____ to keep the infant warm

A

radiant heat warmer

85
Q

Exchange Transfusion: _____ must be maintained at room temperature.

A

Donor blood

86
Q

Exchange Transfusion: Use only _____ to warm the blood

A

commercial blood warmers

87
Q

Exchange Transfusion: The type of blood used for the transfusion is _____ blood.

A

“O” Rh Negative

88
Q

Exchange Transfusion: Post transfusion closely monitor vital signs; signs of umbilical vessel bleeding or infection; and _____ levels

A

bilirubin

89
Q

Conjunctivitis of the newborn

A

Ophthalmia Neonatorum

90
Q

An infection that occurs at birth or during the first month of life, Neisseria gonorrhoeae and Chlamydia trachomatis

A

Ophthalmia Neonatorum

91
Q

Assessment for Ophthalmia Neonatorum

A

● conjunctivae – fiery red, covered with thick pus
● Swollen/Edematous eyelids

92
Q

Therapeutic Management for Ophthalmia Neonatorum

A

● IV Antibiotics - Ceftriaxone
● Ophthalmic Solution - Erythromycin
● Lavage

93
Q

Nursing Management for Ophthalmia Neonatorum

A

● Keep the eye clean
● Wipe from the inner canthus downward & outward
● Warm moist compress
● Instill medications immediately

94
Q

Transmitted to the newborn through contact with infected vaginal blood at birth when the mother is positive for the virus (HBsAg+).

A

Hepatitis B Virus Infection

95
Q

Infants born to mothers whose HBsAg status is
positive should receive HepB and hepatitis B immune globulin (HBIG), ___ ml, within ___ hours of birth at two different injection sites.

A

0.5, 12

96
Q

The vaccine is given intramuscularly in the _____ in newborns or in the _____ for older infants.

A

vastus lateralis, deltoid

97
Q

Nursing Management for Hepatitis B Virus Infection

A

● Infant should be bathed ASAP after birth
● Suction gently
● Immunization
● Breastfeed once HBIG has been administered

98
Q

Gastrointestinal disease wherein the the bowel
develops necrotic patches, interfering with digestion and possibly leading to a paralytic ileus, perforation and peritonitis.

A

Necrotizing Enterocolitis

99
Q

Assessment for Necrotizing Enterocolitis

A

Distended (often shiny) abdomen
Blood in the stools or gastric contents
Gastric retention
Localized abdominal wall erythema
Bilious vomitus

100
Q

Diagnostic Evaluation

A

● Xray (Abdominal)
● Blood Tests
○ CBC
○ Acid Base Balance
○ Electrolytes
● Stool
● Occult Blood Test

101
Q

Therapeutic Management for Necrotizing Enterocolitis

A
  1. Discontinuation of all oral feeding
  2. Minimal Enteral Feedings
  3. Breast milk
  4. Probiotics (Lactobacillus acidophilus and
    Bifidobacterium infantis)
  5. Abdominal decompression via nasogastric suction
  6. Administration of IV antibiotics
  7. Correction electrolyte abnormalities, acid–base imbalances, and hypoxia
  8. Replacing oral feedings with parenteral fluids
  9. Abdominal radiographs
  10. Surgical interventions - ileostomy, jejunotomy, or colostomy
102
Q

Nursing Management for Necrotizing Enterocolitis

A

● Prompt recognition of warning signs
● Vital Signs Monitoring
● Avoid rectal temperature taking
● Undiaper and in supine position
● Nutritional and hydration needs
● Administer antibiotics
● Breast milk
● Infection Control

MCN 2 (4 decks)

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