Chapter 29: High Risk Newborn: Complications Associated with Gestational Age and Development

Question 1

late preterm infants (LPIs)

Answer 1

• born between 34 0/7 and 36 6/7 weeks of gestation
• more stable than preterm infants but are physiologically and metabolically immature and have higher morbidity and mortality than full term infants
• at risk for: hypothermia, respiratory problems, hypoglycemia, hyperbilirubinemia, feeding difficulties, sepsis, long term neurodevelopmental disorders

Question 2

what are contributing factors to late preterm birth?

Answer 2

• elective and medically induced inductions and cesarean births
• preterm labor
• pROM
• preeclampsia
• multifetal pregnancies
• obesity
• assisted reproductive technology
• advanced maternal age
• inaccurate estimate of gestational age before delivery

Question 3

thermoregulation with LPIs

Answer 3

• may develop cold stress that is not noticed until signs appear or until a vital signs check (which often occur only once a shift)
  
  • therefore, nurses should check V/S, esp temp, Q3-4 hours for first 24 hours and then every shift
• kangaroo care: often used to keep infants warm
  
  • it is a method of skin to skin b/w infants and parents

Question 4

feedings with LPIs

Answer 4

• may have immature suck and swallow reflexes, shorter awake periods, and may fall asleep during feedings before being fed enough
• may have difficulty with latch
• have an inc caloric need and should be fed every 2-3 hours
• football and cross cradle holds are helpful to use to help infants feed
• monitor blood glucose at least 2x daily b/c infant at risk for hypoglycemia
• must monitor and document breastfeeding evaluations at least 2x daily

Question 5

discharge of LPIs

Answer 5

• should not be discharged earlier than 48 hours after bith
• infants should be feeding adequately and have normal V/S for at least 24 hours before discharge
• bilirubin levels should be checked
• teach parents to keep infant warm
• car seat challenge: ensure the infant can sit in car seat w/o bradycardia, apnea, or O2 desats
  
  • should be monitored for at least 30 min
• teach parents signs of complications such as jaundice/dehydration
• f/u w/in 24-72 hours

Question 6

what is defined as preterm infant?

what are the 3 categories of prematurity?

Answer 6

• preterm: any infant born before beginning of 38 weeks of gestation
  
  • late preterm: 34-37 weeks
  • moderate preterm: 32-34 weeks
  • very preterm: <32 weeks

Question 7

moderate preterm

Answer 7

• born between 32-34 weeks
• higher risk than late preterm infants for hypothermia, respiratory problems, hypoglycemia, hyperbilirubinemia, feeding difficulties, sepsis, and long term neurodevelopmental disorders
• do not have suck, swallow, breath coordination

Question 8

early/very preterm

Answer 8

• less than 32 weeks gestation
• 24 weeks is point of viability
• 500 grams is indicator of initial survival

Question 9

low birth weight

Answer 9

• low birth weight most often caused by prematurity
  
  • LBW: any infant weighing 5 lb 8 oz (2500 g) or less at birth and of any gestational age
  • very low birth weight (VLBW): infants weighing less than 3 lb 5 oz (1500 g) or less at birth
  • extremely low birth weight (ELBW): infants weighing less than 2 lb 3 oz (1000 g) at birth
• leads to major complications
• often the cause of: preterm labor, chronic health conditions (DM), infection, placental problems, not gaining weight during pregnancy, hx of LBW infants, cigarette/alcohol abuse

Question 10

appearance of preterm infants

Answer 10

• frail and weak
• less developed flexor muscles and muscle tone
• limp extremities with no resistance
  
  • often lie in extended position
• lack subQ tissue or white fat which makes thin skin appear red and translucent
• vernix and lanugo are abundant
• plantar creases are absent if less than 32 weeks
• pinnae of ears are soft, flat, and contain little cartilage
  
  • they lack the rolled over appearance
• female: clitoris and labia minora are large and not covered by labia majora
• male: undescended testes, with smooth scrotal sac

Question 11

behavior of preterm infants

Answer 11

• depends on gestational age
• may have poor development of flexion and little excess energy for maintaining muscle tone
• easily exhausted by noise and activity
• may respond with low O2 levels and stress related behavior
• cry may be feeble

Question 12

problems with respiration in preterm infants

Answer 12

• immature lungs
  
  • presence of surfactant in adequate amounts is of primary importance b/c it allows the work of breathing to be lowered
    
    • if lack of surfactant–>RDS
  • ppor cough reflex and narrowed respiratory passageways

Question 13

assessment of preterm respiratory system

Answer 13

• periodic vs apneic breathing
  
  • periodic: cessation of breathing for 5-10 sec w/o other changes followed by 10-15 sec of rapid respirations
    
    • no changes in color or HR
    • normal
  • apneic: absence of breathing lasting more than 20 sec
    
    • accompanied by cyanosis, pallor, bradycardia, hypotonia
    • may require tactile stimulation and ventilation
• should assess for WOB and location and severity of retractions
• grunting is an early sign of RDS

Question 14

respiratory nursing care of preterm infants: equipment

Answer 14

• respiratory equipment
  
  • O2 hood: if infant can breathe independently but need extra O2
  • NC: can be used if infant breathes well independently
    
    • can be used for home O2
    • should be warmed and humidified
  • CPAP: used to keep alveoli open and improve lung expansion
  • ventilation: when respiratory failure, severe apnea, bradycardia
    
    • can use high frequency ventilation to provide fast respirations w/ less pressure and volume

Question 15

respiratory nursing care of preterm infants: Positioning

Answer 15

• side or prone positions used to help with drainage of secretions
  
  • not recommended in normal infants b/c of SIDS risk
  • in preterm, prone position helps inc oxygenation, enhance respiratory control, improve lung mechanics and volume, and reduces energy expenditure
• start supine sleeping as soon as infant can tolerate
  
  • can often be used at approx 32 weeks

Question 16

respiratory nursing care of preterm infants: suctioning and maintaining hydration

Answer 16

• suction mouth then nose
  
  • only suction as necessary
  • each suction attempt should only be 5-10 seconds long and inc O2 should be provided before and after each attempt
• adequate hydration is important to keep secretions thin so they can be removed by drainage or suction

Question 17

problems with thermoregulation in preterm infants

Answer 17

• skin is thin, blood vessels near surface, and little subQ fat so heat loss is rapid
  
  • preterm so less brown fat was allowed to accumulate
• also they are in extension rather than flexion, so allow more heat loss
• temp control center of the brain is immature
• complications of heat loss: hypoglycemia, respiratory problems, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production

Question 18

assessment of thermoregulation in preterm infants

Answer 18

• temp should be recorded Q30-60 min until stable, then Q1-3 hours
• axillary temp should be between 36.3 deg C and 36.9 deg C
• low temp may be early sign of infection
• hypoglycemia and respiratory distress may be first sign of temp instability

Question 19

signs of inadequate thermoregulation in preterm infants

Answer 19

• axillary temp <36.3 deg C or >36.9 deg C
• abdominal skin temp <36 deg C or >36.5 deg C
• poor feeding or feeding intolerance
• irritability followed by lethargy
• weak cry or suck
• dec muscle tone
• cool skin temp
• mottled, pale, or acrocyanotic skin
• signs of hypoglycemia
• signs of respiratory difficulty

Question 20

nursing care to maintain a neutral thermal environment

Answer 20

• neutral thermal env prevents the need for inc O2 to maintain the infant’s body temp
• delivery room should be warm to dec heat loss at birth
  
  • immediately dry baby (and keep dry) and place on mother or in warmer
  • if less than 29 weeks: wrap in polyethylene bag to prevent evaporative heat loss
• can use open radiant warmers, but be sure to prevent heat loss through convection from drafts
• warmed and humidified O2, b/c thermal receptors in face are very sensitive
• can use heated blankets and hats
• warm formula, breastmilk

Question 21

nursing care to wean an infant to an open crib

Answer 21

• prep for this early
  
  • should keep an infant dressed as much as possible even if in incubator to help infant get used to different temp on face than rest of body
• can begin gradual weaning from external heat if:
  
  • weight about 3 lb 5 oz (1500 g)
  • consistent weight for 5 days
  • no medical complications
  • tolerating feedings
• when move to crib, should double wrap infant to insulate body heat

Question 22

problems with fluid and electrolyte imbalance in preterm infants

Answer 22

• preterm infants lose fluid easliy and loss inc with degree of prematurity
  
  • rapid RR and use of O2 inc fluid loss from lungs
  • thin skin and lack of flexion inc water loss
  • heat from radiant warmers/incubators leads to water loss
• ability of kidneys to conc or dilute urine is poor, so fragile balance between dehydration and overhydration
  
  • normal urinary output: 1-3 mL/kg/hour during first few days
  • after 24 hours: output less than 0.5 mL/kg/hour is considered oliguria

Question 23

assessment of fluid and electrolyte balance in preterm infants

Answer 23

• be on high alert for fluid overload or deficit
• monitor I/O, strictly
• weigh diapers to determine output (1 g=1 mL)
  
  • check specific gravity to determine if dilute or concentrated urine (should be b/w 1.002-1.010)
• daily weights of infant to determine fluid loss or gain
• monitor for signs of dehydration and overhydraiton

Question 24

signs of dehydration in the newborn

Answer 24

• urine output <1 mL/kg/hour
• urine SG >1.010
• weight loss greater than expected
• dry skin and mucous membranes
• sunken anterior fontanel
• poor tissue turgor
• blood: elevated Na, protein, HCT
• hypotension

Question 25

signs of overhydration in the newborn

Answer 25

• urine output >3 mL/kg/hour
• urine SG <1.002
• edema
• weight gain greater than expected
• bulging fontanels
• blood: dec Na, protein, HCT
• moist breath sounds
• difficulty breathing

Question 26

nursing interventions for fluid and electrolyte balance in preterm infants

Answer 26

• regulate IV fluids with a prevision of 0.1 mL/hour
• IV meds diluted in as little fluid as possible
• hourly check of IV site for infiltration
• strict I&O with SG checks
• weigh infants daily

Question 27

skin problems in preterm infants

Answer 27

• skin is fragile, permeable, and easliy damaged
  
  • do not use standard adhesive tape on their skin
  • disinfectants can injure their skin
• assess skin regularly
• nursing interventions:
  
  • avoid adhesives, alcohol, or betadine
  • remove adhesive slowly
  • chlorhexidine gluconate is a common disinfectant that can be used
  • pH balanced cleanser (w/ pH from 5.5-7) should be used for bath (preterm infants should not be bathed every day)
  • humidity in incubators to reduce drying of skin
  • use emollients on skin to help reduce skin fissures
  • frequent position changes to reduce skin breakdown

Question 28

infection in preterm infants

Answer 28

• high rate of infection due to exposure to maternal infection, lack of IgG transfer from mother, immature immune system
  
  • prolonged hospital stays and invasive procedures also inc the risk
• be alert for signs of sepsis
• nursing interventions:
  
  • hand washing
  • no jewelry
  • limit exposure to family and staff who have contagious illnesses
  • strict sterile technique for central lines/dressing changes

Question 29

pain assessment in preterm infants

Answer 29

• pain assessed whenever V/S assessed with NIPS or Premature Infant Pain Profile (PIPP)
  
  • these assess gestational age and behavior states, HR, O2 sats, brow bulge, eye squeeze, and nasolabial furrow
• common signs of pain:
  
  • inc/dec HR and RR
  • inc BP
  • dec O2 sats
  • color changes: red, dusky, pale
  • high pitched, intense, harsh cry
  • whimpering, moaning
  • eyes squeezed shut
  • mouth open grimacing
  • furrowing or bulging of brow
  • tense, rigid muscles or flaccid muscle tone
  • rigidity or flailing of extremities
  • sleep wake pattern changes

Question 30

nursing interventions for pain in preterm infants

Answer 30

• prepare infants for painful precedures by waking them slowly and gently and using containment
  
  • (simulates the enclosed space of the uterus and prevents excessive and disorganized motor activity–>keep extremities flexed w/ swaddling or w/ hands, position in supine or side lying w/ at least 1 of the infant’s hands near the mouth for sucking)
• kangaroo care and breastfeeding can help reduce pain
• nonnutritive sucking on a pacifier
  
  • put sucrose in infant’s mouth 2-3 min before procedure with pacifier
• opioids and acetaminophen

Question 31

signs of overstimulation in preterm infants

Answer 31

• O2 changes:
  
  • BP, pulse, RR instability
  • cyanosis, pallor, mottling
  • flaring nares
  • dec O2 sats
  • sneezing, coughing
• behavior changes:
  
  • stiff, extended arms and legs
  • fisting of hands or splaying of fingers
  • arching
  • alert, worried expression
  • turning away from eye contact (gaze aversion)
  • regurgitation, gagging, hiccupping
  • yawning
  • fatigue signs

Question 32

nursing interventions if an infant is overstimulated

Answer 32

• schedule periods of undisturbed rest throughout the day
  
  • avoid waking infant during quiet sleep phase
  • cluster or group care so more rest allowed w/o interruption
    
    • but keep clustered care short
    • do not include painful procedures in clustered care
  • provide short rest periods during activities
• reduce stimuli: light and sound
• schedule quiet periods that are at least 1 hour long
  
  • promote flexion which helps to reduce energy loss and promotes quieting and reduces stress
• massage
• promoting motor development by keeping infant in an extended, frog leg position
  
  • reposition every 2-3 hours
• individualize care
• communicate an infants’ needs

Question 33

nutrition in a preterm infant

Answer 33

• preterm infants have a lack of fat stores and they use of glucose stores quickly after birth
  
  • hypoglycemia often develops
• have small digestive capacity
• avg healthy preterm infants should gain 15-20 g/kg/day
• poor absorption in gut of fats b/c of insufficient bile acids and lipase
• poor coordination of suck and swallow
• fatigue easily

Question 34

assessment of nutrition in preterm infants

Answer 34

• assess for feeding readiness and tolerance
• gavage
  
  • use until about 33-34 weeks gestation
  • check residual volumes if on enteral feedings to determine if tolerating
    
    • if more than 1/2 of last feeding remains, report it, b/c may be a sign of necrotizing enterocolitis (NEC)
  • vomiting can indicate feedings are too large
  • watch for signs of visible loops of bowel, abdominal distention, ileus, sepsis, obstruction
• nipple feeds
  
  • watch for signs of readniess
  • most infants ready to begin around 34-35 weeks of corrected age
  • assess coordination of suck and swallow and breathing
  • assess RR before and during feedings–>if >60, then use gavage feeding to prevent aspiration

Question 35

what are signs that a preterm infant is ready for nipple feeding?

Answer 35

• rooting
• RR < 60 breaths per min
• inc ability to tolerate holding and handling
• intact gag reflex
• must have enough energy to feed w/o compromised oxygenation
• coordination of suck and swallow

Question 36

adverse signs during nipple feeding

Answer 36

• tachycardia
• bradycardia
• inc or dec RR
• nasal flaring
• markedly dec O2 sats
• cyanosis, pallor
• apnea
• choking, coughing
• gagging, regurgitation
• drooling, gulping
• falling asleep early in feeding
• feeding longer than 20-30 min

Question 37

TPN in preterm infants

Answer 37

• IV infusion of solution containing major nutrients needed for metabolism and growth
• may be necessary due to respiratory problems, limited gastric capacity, surgery, or reduced peristalsis

Question 38

enteral feedings in preterm infants

Answer 38

• also called trophic feedings
• stimulate development of the GI tract, enhance gut motility, dec need for TPN, and shorten hospital stay
• bowel sounds should be present, there should be no abdominal distention, and infants should be stable
• human breast milk or colostrum can be used and is preferred
  
  • but preterm infants often need special formulas or fortified breast milk b/c more easily digested and have more calories (at 24 cal/oz instead of 20)

Question 39

how can a nurse help a mother with a premature infant who wants to breast feed?

Answer 39

• offer support and encouragement and tell her her milk is important to help her baby
• help her to use a breast pump ASAP after birth, then for at least 8 times daily for 10-15 min
• give mom sterile containers to store milk in
• if fortifiers will be put in milk, explain the higher needs of the preterm infant so that the mother does not think something is wrong with her milk
• encourage mom in her efforts
• provide privacy and relaxation
• teach mom to use football and cross cradle holds

Question 40

parenting a preterm infant

Answer 40

• emotionally traumatic experience
• parents cannot hold or feed infant or offer care
• when infant is not capable of normal newborn behaviors or when the infant’s appearance is not what is expected, attachment may be delayed
• extended hospitalization causes separation, produces emotional trauma, and disrupts family life
• guilt and loss of control are common feelings

Question 41

assessment of parents of preterm infants

Answer 41

• assess for signs of parental attachment
  
  • they may be fearful at first, but they should talk about infant in positive terms, make eye contact, name the infant and call it by name
  • they should ask questions about the infant, should smilke and talk to infant
• determine if other stressors in parents’ lives that may interfere with ability to visit and form attachment with infant:
  
  • financial need to work
  • lack of transportation
  • long distances
  • other children

Question 42

signs that bonding may be delayed with a preterm infant

Answer 42

• using negative terms to describe infant
• discussing infant in impersonal or technical terms
• failing to give infant a name or use the name
• visiting or calling infrequently
• dec number/length of visits
• showing interest in other infants equal to their own
• refusing offers to hold and learn to care for infant
• showing dec in or lack of eye contact
• spending less time talking to or smiling at infant

Question 43

nursing interventions for parents of preterm infants

Answer 43

• advance preparations and education
• allow parents to see and touch newborn in delivery room–helps bonding process
• allow father to watch initial care in NICU to allow him to inc confidence in staff and enables him to give mom a full description
• take parents to NICU ASAP
  
  • teach them what to expect, support them as they visit with infant
  • help them hold baby ASAP
• support fathers and encourage them to participate in hands on newborn care
• provide accurate info to the parents
  
  • may often have to repeat things, b/c of emotional stress, they often forget what they heard
• institute kangaroo care

Question 44

kangaroo care

Answer 44

• KC should begin ASAP and is method of providing skin to skin contact
  
  • infant wears only a diaper and a hat and is placed upright under the mother’s clothes b/w the breasts (father can also do KC)
• advantages: opportunity for parents to be involved in care, stabilizes vital signs, inc weight gain, shorter hospital stay, more quiet sleep, less crying, promotes thermoregulation/bonding, helps relieve pain
  
  • upright position also makes breathing easier
  • containment of extremities dec purposeless movement that uses O2 and calories
  • gentile stimulation is provided
• should last at least an hour to improve th einfant’s sleep

Question 45

preparing for discharge with a preterm infant

Answer 45

• begin to teach parents early about procedures, treatments, and meds
  
  • observe the parents and praise their efforts
  • teach them what is normal for their infant and how to respond to abnormal signs
  • help determine any adaptations that need to be made at home
• infants may require O2, cardiorespiratory monitoring, suctioning, gavage or gastrostomy feedings
  
  • feedings will need to happen Q3 hours and may be time consuing
• infants may have a hard time sleeping at first
• assist parent into determining how to integrate new infant into family
• car seat challenge should be performed
• immunizations and hearing screen should be done

Question 46

signs a preterm infant is ready for discharge

Answer 46

• sustained pattern of weight gain, adequate maintenance of body temp in open bed, feeding w/o cardiorespiratory compromise, and stable, cardiorespiratory functioning
• appropriate immunizations given
• car seat challenge completed
• metabolic screening and hearing test performed
• family and home evaluated
  
  • family must have at least 2 members who can feed and provide care, perform CPR, give meds, operate equipment
• f/u care has been scheduled

Question 47

respiratory distress syndrome (RDS)

Answer 47

• condition caused by insufficient production of surfactant in the lungs
  
  • occurs most often in preterm infants under 28 weeks
  • also occurs in birth asphyxia, C/S, multiple births, male gender, cold stress, and GDM–>all interfere with surfactant production
  • less frequent if antenatal corticosteroids or chronic fetal stress (materal HTN or prolonged ROM) occurs
• enough surfactant to prevent RDS not usually made until 34-36 weeks
  
  • if too little surfactant, the lungs become noncompliant or stiff and resist expansion, so WOB inc and retractions result along with seesaw respirations
• tests of amniotic fluid can detect lecithin, sphingomyelin, phosphatidylglycerol, and phophatidylinositol which are components of surfactant
  
  • the test can predict whether the fetal lungs are mature enough for survival of the lungs
  • tests are always performed before an induction or C/S of an infant younger than 38 weeks

Question 48

manifestations of RDS

Answer 48

• begin during 1st hours after birth
  
  • tachypnea
  • tachycardia
  • nasal flaring
  • xiphoid and intercostal retractions
  • cyanosis
  • audible grunting
• acidosis develops as a result of hypoxemia
  
  • inc CO2 and dec O2
• ground glass appearance of lungs of CXR
• signs become worse and peak w/in 3 days then begin to improve

Question 49

therapeutic management of RDS

Answer 49

• surfactant is instilled into the infant’s trachea shortly after birth or as soon as signs of RDS apparent
• O2
• CPAP
• inhaled nitric oxide
• correction of acidosis
• IV fluids

Question 50

bronchopulmonary dysplasia (BPD)

Answer 50

• also known as chronic lung dz
• chronic condition in which damage to infant’s lungs requires prolonged dependence on supplemental oxygen
  
  • occurs most often in infants less than 32 weeks and if VLBW
• patho: results from combo of high levels of O2, oxygen free radicals, and pressure of mechanical ventilation that injure bronchial epithelium and result in inflammation, atelectasis, edema, and airway hyper-reactivity with loss of cilia, thickening of the walls of alveoli, and fibrotic changes

Question 51

BPD: manifestations and management

Answer 51

• manifestations:
  
  • inc need for or an inability to be weaned for respiratory support
  • tachycardia
  • tachypnea
  • retractions
  • crackles
  • wheezing
  • respiratory acidosis
  • cyanosis
  • inc secretions
  • bronchospasm
  • changes on CXR
• aim for prevention
  
  • steroids before birth to reduce prematurity and RDS
  • minimize exposure to O2 and pressure of ventilation
  • avoidance of fluid overload
  • inc nutrition
• tx: supportive therapy: antibiotics and bronchodilators and gradual dec in O2
  
  • diuretics, fluid restriction
  • need frequent rehospitalization

Question 52

intraventricular hemorrhage (IVH)

Answer 52

• it is bleeding into and around the ventricles in the brain
  
  • most common during 1st few days of life in infants less than 1500 grams or less than 32 weeks
  • also occurs in term infants from asphyxia or trauma
• results from rupture of fragile blood vessels in the germinal matrix around the ventricles
  
  • assoc with inc or dec BP, asphyxia or respiratory distress, and inc cerebral blood flow
• hemorrhage graded from 1-4
  
  • 1: small bleed
  • 2: extends to lateral ventricles
  • 3: causes distention of ventricles
  • 4: causes ventricular dilation and extends to other brain tissue

Question 53

IVH: manifestations, management, and nursing considerations

Answer 53

• manifestations: determined by severity of hemorrhage
  
  • poor muscle tone
  • deterioration in respiratory status with cyanosis or apnea
  • dec HCT
  • acidosis
  • hyperglycemia
  • dec reflexes
  • tense fontanel
  • seizure
• management: ultrasounds done to assess
  
  • tx: supportive and focuses on maintaining respiratory function
  • hydrocephalus may develop so a ventriculoperitoneal shunt may be necessary
• nursing:
  
  • avoid situations that may inc the risk of IVH: so keep handling to a minimum, pain and environmental stressors should be reduced
  • daily assessments of hed circumference and changes in neuro status

Question 54

retinopathy of prematurity (ROP)

Answer 54

• condition where injury to the blood vessels in the eye may result in visual impairment or blindness
  
  • more often in infants less than 1000 g and less than 29 weeks
• patho: cause is unknown but high O2 is a risk factor
  
  • prolonged ventilation, acidosis, sepsis, shock, IVH are also risk factors

Question 55

ROP: management and nursing care

Answer 55

• screen infants to detect changes int he eye
• laser surgery can be used to destroy abnormal blood vessels
  
  • may also need cryosurgery (reattachment of the retina)
• nursing:
  
  • check pulse ox if infant receiving O2
  • teach parents about reasons for eye exams
  • mydriatic eye drops used to dilate eyes may cause HTN, bradycardia, apnea

Question 56

necrotizing enterocolitis (NEC)

Answer 56

• this is a serious inflammatory condition of the intestinal tract that may lead to cellular death of areas of intestinal mucosa
  
  • ileum and proximal colon are most affected
• immaturity of the intestine is a major factor
  
  • previous hypoxia of the intestines may be the causative factor
  • incidence is higher after infants receive feedings
    
    • when infants are fed, bacteria proliferate, and gas forming organisms invade the intestinal wall which causes necrosis, perforation, and peritonitis
• breast milk (due to the Igs, leukocytes, and antibacterial agents) may be preventive

Question 57

NEC: manifestations

Answer 57

• inc abdominal girth due to distention
• inc gastric residuals
• dec or absent bowel sounds
• loops of bowel seen thru abdominal wall
• vomiting
• bile stained residuals or emesis
• abdominal tenderness
• signs of infection
• occult blood in stools
• respiratory difficulty
• apnea
• bradycardia
• temp instability
• lethargy
• hypoTN
• presence of air in loops of bowel on radiograph is characteristic of this

Question 58

NEC: therapeutic management and nursing

Answer 58

• supplementing formula with probiotics and breast milk may help prevent NEC
• tx: abx, discontinuaiton of oral feedings, gastric suction, use of TPN to rest intestines
  
  • surgery may be needed if perforation or lack of improvement to remove necrosis (which may lead to short bowel syndrome)
• nursing:
  
  • encourage moms to breast feed
  • early detection–>withhold next feeding and inform provider
  • measure abdominal girth and maintain IV fluids and TPN
  • measure I&O
  • position infant on their side to prevent pressure on diaphragm

Question 59

short bowel syndrome (SBS)

Answer 59

• caused by a bowel that is shorter than normal due to surgical removal or a congenital condition
• patho: dec mucosal surface causes inadequate absorption of fluids, electrolytes, and nutrients
• manifestations:
  
  • malabsorption
  • diarrhea
  • faliure to thrive
• management:
  
  • restore and stabilize fluid and electrolyte balance
  • nutritional support (TPN)
• nursing:
  
  • manage TPN and enteral feedings
    
    • strict aspesis on central venous access device where TPN is infusing
    • advance enteral feedings slowly
  • monitor for signs of electrolyte imbalances

Question 60

problems with post term infants

Answer 60

• those born after 42nd week of gestation
• problems:
  
  • placenta begins to function poorly
    
    • if placental insufficiency–>dec amniotic fluid and compression of umbilical cord may occur–>fetus doesn’t receive appropriate O2 and nutrition–>SGA, hypoxia, malnourishment (postmaturity syndrome)
  • when labor begins, poor O2 reserves may cause fetal compromise
    
    • fetus may pass meconium due to hypoxia and inc risk for meconium aspiration

Question 61

assessment of postterm infants

Answer 61

• if large, assess for injury and hypoglycemia
• if postmaturity syndrome, may have apprehensive look associated with hypoxia
• unusually alert and wide eyed
• may be thin with loose skin and little subQ fat
• no vernix or lanugo, but usually has abundant hair on head and long nails
• may have green staining on cord, skin, and nails
• umbilical cord is thin with little wharton’s jelly
• cracked skin

Question 62

therapeutic management and nursing care for post term infants

Answer 62

• if a mother overdue, placenta is tested for functioning, and if deteriorating, then labor is induced
• apgar scores less than 7 more likely in post-term infants
  
  • may need respiratory support if asphyxia or meconium aspiration occurred
• nurse: prevent complications and monitor for changes in status
  
  • respond to FHR decels, prepare for and assist with emergency delivery
  • if signs of postmaturity, assess for hypoglycemia ASAP
  • temp regulation may be poor b/c of fat stores used up for nourishment in utero
    
    • provide extra blankets, assess temp

Question 63

SGA: causes

Answer 63

• those below the 10th percentile
• causes:
  
  • congenital malformations,
  • chromosomal abnormalities,
  • genetic factors,
  • multiple gestations,
  • fetal infections (rubella, CMV),
  • poor placental functioning or small placental size or malformation,
  • illness in the mother such as pre E or GDM,
  • smoking, drug abuse, alcohol

Question 64

SGA: complications

Answer 64

• low apgar scores
• meconium aspiration
• polycythemia
• hypoglycemia
• inadequate thermoregulation r/t subQ and brown fat stores being used up to survive in utero

Question 65

symmetric growth restriction

Answer 65

• involves the entire body: measurements of the head, chest, length, and weight are below normal, or below the 10th percentile
• caused by congenital anomalies, genetic disorders, exposure to infection or drugs early in pregnancy, genetic predisposition
• body is proportionate and appears normally developed for size
  
  • total number of cells and cell size is dec
  • small throughout their lives

Question 66

asymmetric growth restriction

Answer 66

• caused by complications like pre eclampsia that begin in 3rd trimester and interfere with uteroplacental function
• head is normal in size but seems large for rest of body
  
  • brain growth and heart size are normal
  • length is normal, but weight is below 10th percentile
  • abdominal circumference is dec b/c liver, spleen, and adrenals are small
    
    • SO, head circumference and length are normal, but abdominal circumference and weight are low

Question 67

characteristics of SGA

Answer 67

• infant appears thin, long, waster
• dry loose skin with longitudinal thigh creases from loss of subQ fat
• sunken abdomen
• sparse hair
• thin cord
• facial appearance of being elderly
• anterior fontanel may be wide or overlapping sutures
  
  • usually catch up in growth by 2 years if adequately nourished

Question 68

SGA: management and nursing care

Answer 68

• prevent with good prenatal care
• if suspect SGA is a problem, serial nonstress tests help determine if infant should be born early
• problems should be treated early and as they occur (include asphyxia, meconium aspiration, hypoglycemia, polycythemia, temp instability)
• nursing:
  
  • observe for complication
  • assess for hypoglycemia
  • early and frequent feedings
  • temp regulation and respiratory support
  • observe for jaundice

Question 69

LGA: causes

Answer 69

• those who are above the 90% for gestational age on intrauterine growth charts
  
  • may have macrosomia: weigh between 8 lb 13 oz-9 lb 15 oz (4000-4500 g)
• causes:
  
  • multiparous
  • large parents
  • mothers who are obese
  • ethnic groups known to have large infants
  • GDM
  • erythroblastosis fetalis

Question 70

LGA: complications

Answer 70

• longer labor
• suffer injury during birth
• need a cesarean section
• shoulder dystocia
• fractures of the clavicle or skull
• injury to the brachial plexus or facial N
• cephalohematoma
• subdural hematoma
• bruising
• congenital heart defects
• mortality

Question 71

LGA: management and nursing care

Answer 71

• management is based on identification of increased size during pregnancy by measurements of fundal height and ultrasound
• delivery problems may be managed with the use of vacuum extraction, forceps, or cesarean birth
• nursing:
  
  • assist with difficult delivery
  • assess for injuries, hypoglycemia, polycythemia
  • daily weights
  • assess for congenital heart defects: pulse ox, ECG, CXR

Question 72

what is the problem with preterm infants?

what is the problem with postterm infants?

Answer 72

• preterm: respiratory problems
• postterm: metabolic problems