chapter 17: nursing care of the newborn at risk Flashcards
risk factors that affect the newborn
- premature labor
- diabetes
- hypertension
- placenta abnormalities
- HIV infection
- unhealthy lifestyle
identification of the at risk newborn
- upon admission to labor and delivery, the nurse should review the pregnancy health of the woman
- advanced planning and swift action may prevent long term complications for the high risk newborn
birth asphyxia
- known as preinatal asphyxia, asphyxia neonatorum, or hypoxic ischemic encephalopathy
- defined as acute brain injury caused by asphyxia when the baby did not get enough oxygen during the birth process
possible causes of birth asphyxia
- mother does not get enough oxygen during labor
- mother’s bp is too high or too low during labor
- placenta separates from the uterus too quickly, resulting in loss of oxygen
- the umbilical cord wrapped too tightly around the neck or body
- fetus is anemic and does not have enough RBCs to tolerate labor contractions
- newborn’s airway becomes blocked
- delivery is too long or too difficult
pathophysiology of birth asphyxia
- asphyxia slows or ceases breathing
- lack of prefusion of blood to the brain and other organ systems
- hypoxia forces cells to undergo anaerobic respiration
- lactic acid forms and tissues become damaged
- lack of oxygen affects the brain, muscles, and heart first
- heart dysfunction causes hypotension
- when adequate blood perfusion returns, the brain swells causing more neurological problems
signs and symptoms of birth asphyxia
- cyanosis
- difficulty breathing
- gasping respiration
- umbilical cord ph less than 7
- Apgar score of less than 3 for more than 5 minutes
management of birth asphyxia
- immediate neonatal resuscitation if needed
- transfer to NICU if symptoms are severe or persistent
possible causes of respiratory distress of the neonate
- asphyxia at birth
- lack of surfacant in the lungs with a premature birth
- fluid in lungs
- meconium aspiration
- pulmonary hypertension
- cold stress
- conditions affecting the newborn’s ability to breathe
- nurse’s should identify early stages of respiratory distress and initiate care to provide oxygenation, improve gas exchange, and prevent more complications or death
respiratory distress syndrome (RDS) of teh nwborn
- caused by a lack of surfacant in and immaturity of the fetal lungs
- seen in premature infants, infants experiencing birth asphyxia, newborns of diabetic mothers, and those born by cesarean section
- formerly known as “hyaline membrane syndrome” due to the formation of hyaline membranes that line the alveoli and impair ventilation
pathophysiology of respiratory distress syndrome of the newborn
- absence of surfacant causes the alveoli not being able to stay open for oxygenation
- hypoxemia and hypercapnia occur, leading to respiratory acidosis
- acidosis causes vasoconstriction and damages the epithelium of the lungs, leading to hyaline membrane formation inside the alveoli
hypercapnia
elevated carbon dioxide
signs and symptoms of respiratory distress syndrome evident at birth or within 8 hours of life
- tachypnea
- dyspnea
- grunting w/ expirations
- nasal flaring
- intercostal retractions
- cyanosis
medical management of respiratory distress syndrome of the newborn
- antenatal corticosteroids
- transfer to NICU
- surfacant therapy
- oxygen therapy
- continuous positive airway pressure
- mechanical ventilation support, if needed
- vapotherm
- neonatal cpr, if indicated
- administer ordered medications and fluids
- monitor respiratory and oxygenation status
- provide emotional support to the family
vapotherm
heated and humidified high flow oxygen through a nasal cannula
trasient tachypnea of the newborn (TTN)
- a common self limiting condition of infants in which tachypnea, increased oxygen needs, and mild respiratory distress occur
- commonly occurs in infants sedated from maternal pain medications, prolonged labor, macrosomia, and babies born via cesarean section
- caused by incomplete reabsorption of fluid in the lungs and usually resolves within 3-5 days
meconium aspiration syndrom
- fetal distress may decrease oxygen and cause the fetus to pass meconium into the amniotic fluid
- meconium can block the infant’s bronchioles, causing poor oxygenation, pneumonia, and pneumothorax
- mainly affects term and postterm newborns
signs and symptoms of meconium aspiration syndrome
- greenish yellow staining of the skin, nail beds, or umbilical cord
- tachypnea
- retractions, nasal flaring, grunting
- decreased oxygen saturation levels
- decreased breath sounds
management of meconium aspiration syndrome
- thorough suctioning with the first breath
- endotracheal intubation and mechanical ventilation, if indicated
- transfer to NICU
- medical and nursing care is the sam eas discussed for the newborn with respiratory distress
pathophysiology
- fetal circulation persists, or remains, as it was in the uterus
- ductus arteriosus and/or foramen ovale remain open
- blood is shunted away from the lungs, the lungs have high pressure, and there is inadequate blood flow to the lungs for oxygenation
common causes of persistent pulmonary hypertension of the hypertension
- perinatal asphyxia
- RDS
- neonatal sepsis
- congenital defect of the heart or lungs
signs and symptoms of persistent pulmonary hypertension of the newborn
- similar to RDS
- cyanosis that does not improve with administration of oxygen
- shock: low bp and tachycardia
- possibility of a heart murmur caused by the open ducts arteriosus and/or foramen ovale
management of persistent pulmonary hypertension of the newborn
- begins with transfer to the nicu
- may resolve, or infant may have ongoing health problems
- infant has a higher risk of neurosensory hearing loss and neurodevelopmental problems later
care of the newborn w/ cold stress
- the risk of cold stress is highest during the immediate transitional period after birth
- more likely to occur if born outside of the hospital environment
- normal rectal temp for term and preterm infants: 97.7-98.6 F
neonatal hypoglycemia
- plasma glucose level of less than 30 mg/dl in the first 24 hours of life and less than 45 mg/dL thereafter
- the most common metabolic problem in newborns, affecting both healthy and ill appearing infants
- 95% of the available glucose is used for brain function in newborns
long term complications from frequent or prolonged hypoglycemia are neurological damage such as
- intellectual disability
- development delays
- personality disorders
- decreased head size
- seizures
check the blood sugar with a …
heel stick blood sample
- always check the blood sugar immediately after birth for any large or small birth weight newborn
a newborn’s blood glucose levels cacn drop if the newborn
- has no glycogen sored in the liver
- hased used up stored glucose for heat production or a birth stress
- is an IDm and has hyperinsulinism
- cannot feed enough to keep glucose level in an acceptable range
birth injuries
- can occur as a result of traction and compression during the birthing process
- also known as “birth trauma”
risk factors for birth injuries
- fetal macrosomia
- cephalopelvic disproportion
- prolonged or very rapid delivery
- use of forceps or vacuum extraction
- abnormal presentation, such as breech
- large fetal head
common soft tissue injuries…
resolve within days and cause no long term problems for the infant
- cephalohematoma, caput succedaneum, abrasion, or lacerations from instrumental deliveries
_________ are less common, but have potential for more complications
brachial plexus injuries, cranial nerve injuries, and fractures
brachial plexus injuries
- occur from an increase in the infant’s neck shoulder angle resulting in a traction force to the brachial plexus
- occur in 0.5 to 1,00 live births and associated w/ large birth weight, long labors, vaginal breech delivery, and shoulder dystocia
brachial plexus
a network of nerves originating in the neck area that branch off to form the nerves that control movement and sensation in the shoulders, arms, and hands
symptoms of brachial plexus injuries
- limited movement on one side of the body
- no Moro reflex on the affected side
- claw like appearance of the hand on the affected side
- abnormal muscle contractions on the affected side
definitive diagnosis of brachial plex injuries may include…
x rays to determine a fracture of the clavicle, shoulder, or arm; imaging studies; and nerve conduction studies
medical management of brachial plexus injuries
- physical therapy (ROM activities, massage, stretching)
- surgical treatment (nerve graft)
nursing care of the brachial plexus injuries
- report symptoms of brachial plexus injury immediately
- protect the affected arm from dangling when held or moved
- do not lift the infant under the axillae
- teach parents how to support the affected arm with rolled blankets when infant is in the car seat and crib
- monitor for signs of pain and report to the provider
- position the infant w/ a good body alignment
- provide emotional support to the family
fractures
- the clavicle is the most frequently fractured bone
- associated w/ macrosomic infants and infants w/ large shoulders, making vaginal delivery difficult
signs and symptoms of fractures
- newborn does not move the affected arm
- a plapable bone irregularity may be noted during physical assessment
- diagnosis is made w/ an x ray of the clavicle and affected arm
- heals in 7 to 10 days
- care includes immobilizing the arm and observing for possible brachial plexus injury
hyperbilirubinemia
- the most common condition that requires medical attention in newborns; also known as “jaundice”
types of jaundice
physiologic jaundice
pathological jaundice
pathological jaundice
- the serum bilirubin levels rises excessively and requires treatment to accelerate removal from the blood before complications can occur
- the serum bilirubin is excessively elevated; the skin becomes saturated w/ bilirubin, causing the yellow coloration; the bilirubin begins to deposit in the brain and can cause neurotoxcity (kiernickterus)
risk factors of hyperbilirubinemia
- prematurity
- blood type incompatability with the mother
- lack of effective breastfeeding
- excessive bruising from an extended labor or a malpresentation in labor, such as face presentation
signs and symptoms of hyperbilirubinemia
- visually detected when level reaches 5-6 mg/dL, first appears on the face; sclera may be tinted yellow also
- yellow color spreads down the body as bilirubin level rises
transcutaneous bilirubinometer is a…
noninvasive instrument that gives an estimate of the total bilirubin before a serum bilirubin test is performed
- definitive diagnosis is made through laboratory testing
medical management of hyperbilirubinemia
- breastfeeding or bottle feeding
- breastfeeding at least 8-12 times or bottle feeding 8 -10 times a day
- 6 wet diapers and three stools per day is most favorable to eliminate bilirubin through the GI tract and kidneys
phototherapy
- used when total serum bilirubin level is at or above 15 mg/dL in infants 25 to 48 hours old, 18 mg/dL in infants 49 to 72 hours old; 20 mg/dL in infants older than 72
- uses a “blue light” through overhead lights, pads, or blankets to convert bilirubin molecules into water soluble compounds that can be excreted by the body
- infant’s eyes must be covered to prevent damage tro the retina from the bright light
exchange transfusions
- a blood exchange transfusion in the NICU may be required if kernickterus occurs
- serious neurological damage may result if the bilirubin levels do not drops w/ feedings and phototherapy
nursing interventions for hyperbilirubinemia
- encourage breastfeeding 8 to 12 times a day, or bottle feeding 8 to 10 times a day
- monitor the number of stools
- weigh diapers for accurate urine output information
- place eye patches to protect newborn’s eyes during phototherapy
- expose the maximum amount of skin to the light, except for the genital area
- monitor newborn’s behavior; irritability or lethargy could indicate that the bilirubin level is irritating the brain
- monitor body temp for hypothermia from being undressed
care of the newborn w/ an infection
- newborns can be exposed to infection from the mother from organisms that enter teh vagina during labor, from contaminated hospital personnel and equipment, and from family and visitors
- a newborn’s immune system is immature and unable to fight against severe infection before it becomes systemic
neonatal sepsis
- blood infecion that presents within the first 28 days of life; chemical released into the blood to help fight the infection cause inflammation over the entire body
most common causes of neonatal sepsis
- group B strep
- e. coli
- herpes
herpes as a cause for infant sepsis
- virus may infect the newborn during pregnancy, labor, or delivery
types of herpes
- herpes virus type (oral)
- herpes virus type 2 (genital) the most common for newborns
- the fetus can be exposed while passing through the birth canal if the mother has an active case of herpes type 2 at the time of delivery; a scheduled cesarean birth should be done
signs of herpes
- includes skin infection that blisters, crusts over, then heals
- can become systemic and life threatening
- symptoms of a systemic neonatal herpes infection are identical to the manifestations of neonatal sepsis
- management is also the same except for antibiotics; the newborn will receive antiviral medications instead
preterm birth
les than 37 weeks, 6 days
early term birth
from 37 week 6 days through 38 weeks, 6 days
full term birth
from 39 weeks through 40 weeks, 6 days
late term birth
from 41 weeks through 41 weeks, 6 days
post term birth
42 weeks and beyond
SGA/intrauterine growth restriction (IUGR) newborn
- an SGA newborn is an infant whose weight is les than the 10th percentile for his or her gestational age
- the SGA newborn may have been affected by intrauterine growth restriction (IUGR), limited fetal growth caused by a decrease in placenta perfusion during gestation
possible causes of SGA
- abnormalities of the placenta or vessels restricting nutrients and oxygen to the developing fetus
- maternal hypertension
- uncontrolled, severe maternal diabetes
- poor maternal nutrition
- maternal drug use or heavy smoking
- exposure to teratogenic substances
- maternal alcohol consumption
- multigestation
- parents of small stature
SGA/Intrauterine Growth Restriction (IUGR) Newborn diagnosed during…
pregnancy at route visits upon measurement of fundal height and through ultrasound examination
physical findings of infants w/ IUGR
- weight, length, and head circumference all below the 10th percentile for gestational age
- large head in relationship to the rest of the body
- thin extremities and trunk
- loose skin
- thin umbilical cord
risks for term SGA infants
- perinatal asphyxia during labor, if SGA was due to placental insufficiency
- meconium aspiration
- hypoglycemia
- hypothermia
nursing interventions for SGA newborns
- perform a gestational age assessment
- observe for respiratory distress
- detect tremors or jitteriness, which are early signs of hypoglycemia
- institute early feeding to prevent hypoglycemia
- monitor for hypothermia
- monitor for vital signs and daily weight
- teach parents on keeping the infant warm and to provide frequent feedings
the large for gestational age (LGA) newborn is an…
infant whose weight is greater than the 90th percentile for gestational age
- predominant cause is maternal diabetes
most common complications for LGA newborn
- shoulder dystocia
- fracture of the clavicle or limbs
- perinatal asphyxia
- meconium aspiration
- respiratory distress
- hypoglycemia
assessment findings for LGA newborns
- large, obese baby
- listless, apathetic bab
nursing interventions for LGA newborns
- perform a gestational age assessment
- assess respiratory status
- assess and report for signs of birth injuries
- monitor for tremors
- provide frequent feedings
preterm newborn
infants born before 37 weeks’ gestation and have an increased risk of complications and mortality
risk factors for preterm birth
- low socioeconomic status
- cigarette smoking
- prior premature births
- multiple prior therapeutic or spontaneous abortions
- little or no prenatal care
- poor nutrition
- untreated infections
- pre eclampsia
- multiple gestation
physical assessment of preterm newborn findings
- skin is thin, and arteries and veins are visible
- skin is fragile, and looks smooth and shiny
- a moderately premature infant will have abundant lanugo
- partially formed fingernails and toenails
- ears may fold
- very preterm infants have less muscle tone
- the premature baby does not lie in a “fetal position” until 35 weeks
potential complications of prematurity
- respiratory distress
- hypothermia
- heart problems: patent ductus arteriosus and hypotension
- intraventricular hemorrhage in the brain
- anemia
- infection
- fluid and electrolyte imbalances
- apnea of prematurity
necrotizing entertocolitis (NEC)
- the damage to the intestinal tract that may have occurred from abnormal intestinal flora, immaturity of the intestinal mucosa, intestinal ischemia, and a genetic predisposition
- may effect only the mucosal lining, or may be full thickness necrosis and bowel perforation
signs and symptoms of necrotizing enterocolitis
- vomiting
- diarrhea
- delayed gastric emptying
- decreased bowel sounds
- lethargy
- increased abdominal girth
- visible intestinal loops
- palpable abdominal mass
- hematochezia (bright red blood in the stool)
medical management of preterm newborns includes
stopping formula feedings, insertion of a nasogastric tube, feeding with breastmilk, and administration of antibiotics
- surgical intervention may be required to remove perforated or necrotic intestinal tissue
retinopathy of prematurity (ROP)
- visual impairment and blindness
- early surgical laser treatment is the treatment of choice
delayed development and preterm newborns
- most babies catch up by 12-18 months and meet developmental milestones of their crrected ages
- corrected age - baby’s actual age in weeks or months minus the number of weeks or months of prematurity
- premature infants are at risk for learning disabilities and neurological problems such as ADHD
long term complications of prematurity
- retinopathy of prematurity
- cerebral palsy
- delayed development
post term newborn
- infants born after 42 weeks’ gestation
- unknown cause
- in some cases, the placenta begins to detach and break down leading to placental insufficiency syndrome; the lack of adequate nutrition and oxygen results in an SGA infant
characteristics of post term newborns
- more alert than a term infant
- decreased subcutaneous fat, loose skin
- dry, peeling skin
- lack of vernix and lanugo
- long fingernails and toenails
- meconium staining on the umbilical cord
potential complications in post term newborns
- stillbirth or neonatal death
- prolonged labor and birth trauma due to larger body size
- hypoglycemia
- increased risk of meconium aspiration
neonatal complications are directly related to…
inadeqte glucose control in pregnancy
congenital malformations
- high blood sugar concentrations are toxic to cell growth in the first trimester
- may cause cardiac and CNS abnormalities of the fetus
- cardiomegaly
- spina bifida
nursing interventions for congenital malformations
- promptly identify congenital abnormality, if obvious
- notify the provider of physical abnormalities or abnormal vital signs
fetal macrosomia
- an infant weighing more than 4000g at birth
- occurs in 15% to 45% of diabetic pregnancies
- high levels of maternal glucose lead to fetal hyperglycemia and hyperinsulinemia, which causes increased growth in the fetus
vaginal birth increases risk for birth injuries caused by….
shoulder dystocia
the macrosomic IDM is typically delivered via
cesarean birth
the macrosomic IDM appears…
ruddy, fat, puffy, and may have decreased muscle tone at birth
nursing interventions for fetal macrosomia
- notify the provider of birth weight and signs of macrosomia
- perform a gestational age assessment
- observe for signs of birth injuries
- observe for signs of hypoglycemia
hypoglycemia
- due to a rapid fall in glucose within an hour of birth
- linked to fetal hyperinsulinism
fetal hyperinsulinism
- the fetus produces high levels of insulin in response to the maternal glucose
- when the cord is cut, the glucose influx is over, and fetus is left with high levels of circulating insulin leading to hypoglycemia
fetal hypoxia
- poorly controlled maternal diabetes can lead to a decreased supply of oxygen (hypoxia) to the fetal tissues and decreased blood flow to the placenta
- chronic fetal hypoxia can lead to intrauterine death or to respiratory depression at birth
- the fetus attempts to compensate for the decreased oxygen by producing extra red blood cells, a condition called polycythemia
polychythemia
- diagnosed when the hematocrit is greater than 65%
- increases the risk of strokes, seizures, and hyperbilirubinemia
characteristics of polycythemia
- ruddy skin
- sluggish capillary refill time
- respiratory distress, apnea, cyanosis
- poor feeding
- lethargy
- seizures
- hematuria
medical management of polycythemia
- frequent monitoring of the vital signs, hematocrit, and blood glucose
- some physicians will perform a partial blood exchange transfusion w/ saline to decrease the hematocrit quickly in symptomatic infants
- in asymptomatic infants, observe for the onset of any symptoms and t the body adjust to the hematocrit; some physicians will hydrate the newborn with IV fluids
nursing interventions for polycythemia
- notify the provider immediately of any signs and symptoms
- infuse IV fluids, if ordered, and observe closely for signs of fluid overload
hypocalcemia
calcium level less than 8 mg/dL
hypomagnesemia
magnesium level less than 1.7 mg/dL can occur in IDM
pathophysiology of mineral/electrolyte metabolism
- poor control of maternal glucose leads to maternal glycosuria, which is accompanied by magnesium loss, which causes fetal deficiency
- insufficient magnesium level causes loss of calcium
- severe hypomagnesemia causes a secondary hypocalcemia and hypoparathyroidism
hypoparathyroidism
decreased secretion or activity of the parathyroid hormone, because magnesium is needed for the appropriate secretion of the PTH
medical management of mineral/electrolyte metabolism
- screening for hypocalcemia and hypomagnesemia
- administering calcium and magnesium to obtain normal levels
signs and symptoms of mineral/electrolyte metabolism
- poor feeding
- lethargy
- tremors, seizures
- cardiac arrhythmias
- respiratory distress
nursing interventions for mineral/electrolyte metabolism
- report abnormal signs and symptoms immediately to the provider
- maintain close observation to detect deterioration
- administer calcium and/or magnesium as ordered
- provide education and emotional support to the family
neonatal abstinence syndrome
a group of similar behavioral and physiological signs and symptoms in the neonate caused by withdrawal from various pharmacologic agents
withdrawal symptoms of chemically exposed infants depends on
- age of the neonate
- drug
- drug’s half like
- time of the mother’s last use
neonatal abstinence scales are tools used to evaluate newborn…
reflexes and behavioral that indicate the severity of withdrawal symptoms and plan for medical interventions
medical interventions for neonatal abstinence
- transfer to NICU
- intravenous fluids as ordered
- provide medications to reduce symptoms and gradually wean from the substance (morphine is most frequently used medication for opioid addicted newborns)
- administer phenobarbital as ordered to control seizures
- avoid administering naloxone to the mother at the time of delivery; it causes abrupt withdrawal and seizures for the neonate
nursing interventions for chemically exposed infants
- assess for signs of withdrawal and report any signs and symptoms immediately
- administer and monitor pharmacological treatment
- protect the skin from diarrhea
- bottle feed with high calorie formula
- encourage breastfeeding if not contraindicated
- provide parenting education to the caretakers
- communicate w/ and provide a referral to a social worker for post discharge care and follow up
long terms effects for chemically exposed infants
- poor growth throughout childhood
- hyperactivity and add
- impaired cognition
- poor language development
- higher rated of criminal behavior and substance use disorder
perinatal transmission
- transmission of HIV from mother to child during pregnancy, labor and delivery, or breastfeeding
- the risk of perinatal acquisition is 25% to 40% without interventions such as antiviral therapy
- CDC recommends that infants born to mothers with unknown HIV status should receive rapid HIV testing
medical management of the HIV exposed newborn
- if the mother received antiretroviral medications during pregnancy: Zidovudin (ZDV) 4mg/kg twice a day through 6 weeks of age
- if the mother did not receive prenatal antiretroviral medications: ZDV 4mg/kg twice a day through 6 weeks of age
- Nevirapine (NVP) 3 doses in the first week of life; 12 mg PO per dose if birth weight is greater than 2 kg, and 8 mg per dose if birth is 1.5-2kg
nursing interventions for newborn exposed to HIV
- maintain strict standard precautions
- anyone handling the newborn, including family members, must wear gloves until the first bath
- assess and notify hcp of any abnormalities
- administer medications as ordered
- pt teaching on the importance of following the drug prophylaxis plan after discharge
- advise the mother not to breastfeed
care of the family of an at risk newborn
- fear of the unknown and the NICU environment
- anger
- gueilt, because the mother often blames herself
- loss of bonding and attachment time
- loss of control
- frustration
- anxiety about the baby’s health
- helplessness because the parent’s cannot provide the high skilled level of care needed by the infant
family centered nursing interventions for at risk newborns
- provide opportunity for parents to hold and bond w/ newborn
- develop a therapeutic relationship with the parents
- provide positive reinforcement for their concerns
- encourage parents to talk about their NICU experience
- never behave as if the parents are in the way or interrupting
