High Risk Neonate Flashcards
What high risk conditions are associated with prematurity?
Retinopathy of prematurity Bronchopulmonary dysplasia Hypo/hyper thermal Sepsis Intraventricular hemorrhage Necrotizing enterocolitis Effect of prematurity on growth and development
What two conditions are part of respiratory distress syndrome?
Retinopathy of Prematurity
Bronchopulmomary dysplasia
What conditions are associated with issues with gestational age?
SGA
LGA
IUGR
Post maturity syndrome
What are two types of IUGR?
Symmetric IUGR
Asymmetric IUGR
What condition is part of post-maturity syndrome?
Meconium aspiration syndrome (MAS)
What conditions are part of congenital anomalies?
Neural tube defects
Cleft lip/palate
Imperforate anus
Dislocated hip/club foot
GA: preterm infant
20-37 weeks
GA: late preterm infant
34-36 6/7 weeks
GA: Full term infant
39-40 6/7 weeks
GA: Late term infant
41-41 6/7 weeks
GA: Post-term infant
42 weeks and beyond
Infants who are __ or __ have 20x greater risk for death
IUGR or SGA
Low birth weight baby
<2500 grams
Less than 5.5 pounds
Regardless of gestation age
Very low birth weight baby
<1500 grams or <3.3 lbs
Extremely low birth wight baby
<1000g
<2.2 lbs
Small for gestational age baby
Plot below 10th percentile
Appropriate for gestational age baby
Plot between the 10th and 90th percentile
Large for gestational age baby
Above the 90th percentile or >4000g
How is IUGR defined?
Rate of growth does not meet expected growth pattern
What is symmetrical IUGR?
Weight, length, and head circumference all affected
What is asymmetrical IUGR/
Head normal, but body is disproportionally small (<10th percentile)
Preterm labor defined as…
Labor between 20-37 weeks of pregnancy
What is the number one perinatal and neonatal problem in the USA?
Pre term labor
Preterm labor accounts for __ of live births
11.4%
What are the fetal implications for preterm labor?
Increased morbidity and mortality
Increased risk of birth trauma
Maturational deficiencies
What is the number one cause of death among infants?
Preterm birth
What types of births account for the majority of preterm mortalities?
Peri-viabe births
What is the chance of survival at 22 weeks?
6%
What is the chance of survival at 23 weeks?
26%
What is the chance of survival at 24 weeks?
55%
What is the chance of survival at 25 weeks?
72%
Self-care measures to prevent preterm labor:
A mother should rest…
2-3 times per day laying on her left side
Self-care measures to prevent preterm labor:
Drink __ amount of fluid each day and avoid…
2-3 quarts
caffeine
Self-care measures to prevent preterm labor:
Empty bladder at least…
Every 2 hrs during waking hours
Self-care measures to prevent preterm labor:
Avoid lifting…
Heavy objects. Have small children climb onto lap instead of picking them up
Self-care measures to prevent preterm labor:
Avoid prenatal breast preparation such as…
Nipple rolling or rubbing nipples with a towel to avoid uterine irritability
Self-care measures to prevent preterm labor:
Pace necessary activities to avoid…
overexertion
Self-care measures to prevent preterm labor:
Eliminate sexual activity that leads to…
Orgasm or includes nipple stimulation
Self-care measures to prevent preterm labor:
Find pleasurable ways to help compensate for…
Limited sexual practices
Self-care measures to prevent preterm labor:
Try to focus on…
one day at a time rather than long periods of time
Self-care measures to prevent preterm labor:
If on bed rest get…
dressed each day and rest on couch rather than isolated to the bedroom
What social factors are risk factors for preterm labor?
African American race Smoking or substance abuse Low socioeconomic status Limited education Late entry prenatal care High levels of personal stress
What are health factors that increase the risk for preterm labor?
History of genital tract infection Bleeding during pregnancy Uterine anomaly Infertility treatment Multi fetal pregnancy Underweight or obese Periodontal disease
What are common causes of INDICATED preterm birth
DM or GDM Chronic hypertension Pre-eclampsia Obstetrical disorders Medical disorders AMA Fetal disorders
What does TTTS stand for?
twin to twin transfusion syndrome
What is TTTS?
The blood supply of one twin moves to the other and one is deprived of blood
When does TTTS occur?
Only in identical twins
Women with cervix length greater than __ are unlikely to give preterm birth even in the presence of contractions
30mm
How can preterm labor be predicted?
Using cervical length and fetal fibronectin
Which method of predicting preterm labor is not very effective? and why?
Using cervical length because changes in length occur over several weeks
What does FFN stand for?
fetal fibronectin
What is fetal fibronectin?
Glycoprotein found in vaginal and cervical secretions
How is a FFN test done?
Using a swab to collect secretions during a vaginal speculum exam
The FFN test is most valuable to detect who will…
NOT go into preterm labor
A negative FFN test means
the patient will not go into preterm labor
A negative FFN value is __
high
Women who have a high FFN value have a…
<1% chance of going into preterm labor within the next 2 weeks
How is preterm labor suppressed?
Tocolytics
What tocolytic is used to stop preterm labor?
Magnesium sulfate
How is magnesium sulfate given?
40g/1000cc piggyback to primary infusion
What is the loading dose of magnesium sulfate?
4-6g over 20-30 mins
What is the maintenance dose of magnesium sulfate?
1-4 grams per hour
What are side effects of magnesium sulfate?
Feeling flushed
Nausea and vomiting, weakness, dizziness
What is the therapeutic range of magnesium sulfate?
5-8 mg/dL
Why is magnesium sulfate given?
For near protection during preterm labor for women 24-32
When is magnesium sulfate stopped?
Shouldn’t be on longer than 24 hours
What respiratory rate should the nurse discontinue the mag sulfate?
RR <12
What urine output should the nurse discontinue the mag sulfate?
<25-30 mL/hr
What serum magnesium level should the nurse discontinue the mag sulfate?
9 mg/dL or higher
What patient s/s should the nurse discontinue the mag sulfate?
Pulmonary edema Absent DTRs Chest pain Severe hypotension Altered LOC Extreme weakness
How does terbutaline work?
Smooth muscle relaxant and bronchodilator
How is terbutaline given?
SQ injection
What is the dose for terbutaline?
0.25 mg every 4 hrs for 24 hrs
What type of drug is terbutaline?
B mimetic
What are side effects of terbutaline?
Palpitations, tachycardia, headache, nausea, vomiting, hypotension, hyperglycemia
When should terbutaline be discontinued?
HR >130 BP <90/60 Chest pain Arrhythmia MI Pulmonary edema
A patient with heart disease is having toxic effects of magnesium, can you give her terbutaline?
NO
A patient with diabetes is having toxic effects of magnesium, can you give her terbutaline?
NO
A patient with preeclampsia is having toxic effects of magnesium, can you give her terbutaline?
NO
A patient with hyperthyroidism is having adverse effects of magnesium, can you give her terbutaline?
NO
A patient with chorioamnionitis is having toxic effects of magnesium, can you give her terbutaline?
NO
A patient who is hemorrhaging is having adverse effects of magnesium, can she be given terbutaline?
NO
What medication is given to reverse cardiac effects of terbutaline?
Inderal
What tocolytic suppresses uterine smooth muscle by inhibiting prostaglandin?
Indomethacin/indocin
What is the dosage of indomethacin/indocin?
Intially 50 mg PO and then 25-50mg every 6 hrs for 48 hrs
Indomethacin/Indocin is only used gestations __ weeks
less than 32
Why is indomethacin/indocin only used in gestations less than 32 weeks?
Must have adequate amniotic fluid volume and function of ductus arteriosus before beginning treatment
What are the maternal side effects of indomethacin/indocin?
Nausea Vomiting Heartburn GI bleeding Thrombocytopenia
What are the fetal side effects of indomethacin/indocin?
Constriction of ductus arteriosus
oligohydramnios
neonatal pulmonary hypertension
A mother with renal disease is going into preterm labor. Can you give her indomethacin/indocin?
NO
A mother with liver disease is going into preterm labor. Can you give her indomethacin/indocin?
NO
A mother with active peptic ulcers is going into preterm labor. Can you give her indomethacin/indocin?
NO
A mother with poorly controlled asthma is going into preterm labor. Can you give her indomethacin/indocin?
NO
A mother with hypertension is going into preterm labor. Can you give her indomethacin/indocin?
NO
A mother with a coagulation disorder is going into preterm labor. Can you give her indomethacin/indocin?
NO
What are the contraindications of indomethacin/indocin?
Renal or liver disease Active peptic ulcers Poorly controlled asthma Hypertension Coagulation disorders
What are brand names of nifedipine?
Adalat
Procardia
What type of medication is nifedipine?
Calcium channel blocker
How does nifedipine work?
Calcium channel blocker - works by relaxing smooth muscle by blocking calcium entry
What is the usually prescription for nifedipine?
10-20 mg PO q 3-6 hrs until contractions have stopped or are rare
After a patient has finished the first prescription of nifedipine, what is the second prescription?
30-60 mg long acting every 8-12 hrs for 48 hrs while steroids are given to baby for lung maturity
What are the side effects of nifedipine?
Head ache, flushing, dizziness, hypotension
What two medications are contraindicated while using nifedipine?
Magnesium sulfate
terbutaline
Why is mag sulfate contraindicated with the use of nifedipine?
Skeletal muscle blockade
Why is terbutaline contraindicated with the use of nifedipine?
Effects on heart rate and blood pressure
What method of administration is contraindicated for nifedipine?
Sublingual
What is the major syndrome preterm babies are at risk for developing?
Respiratory distress
Why are preterm babies at risk for developing respiratory distress?
Have not yet developed adequate alveoli in their lungs where surfactant is produced
What are alveoli?
the terminal air scas at the ends of each lung branch
What is the role of surfactant in the lungs?
acts like a grease to keep the lung surfaces slippery so they don’t stick together and cause atelectasis
What is the last part of the lung to form?
Alveoli
How can surfactant development be stimulated in a preterm baby?
Giving the mother betamethasone
Rupture of membranes
Why two steroids are given for fetal lung maturity?
Betamethasone
Dexamethasone
What type of steroids are given for fetal lung maturity?
Glucocorticoids
What other organs do betamethasone and dexamethasone help to mature?
Kidneys
Brain
Gut
What is the MOA of glucocorticoids for lung maturity?
Releases enzymes that cause production of lung surfactant
What gestational age are preterm babies able to get betamethasone injection?
24-34 weeks
Why are steroid injections given when the baby is 24-34 weeks?
These babies have reduced risk of inter ventricular hemorrhage, NEC, and neonatal death
What is the dosing of betamethasone?
12 mg IM x 2 doses 24 hrs apart
What is the dosing of dexamethasone?
6 mg IM x 4 doses 12 hrs apart
Where should the nurse administer beta or dexamethasone?
DEEP IM in the ventral gluteal or vests lateralis
What are nursing considerations for administering betamethasone/dexa?
Injection is painful
Assess blood glucose levels
Women will DM may need increased insulin
What skeletal issue do preterm babies have that make them at increased risk for respiratory distress?
Bony thorax is insufficiently calcified/hardened so it collapses easily
What respiratory problem do preterm babies have that puts them at risk for distress?
Respiratory passages are tiny and easily obstructed
Weak or absent gag reflex
What are four treatments for respiratory distress syndrome in preterm babies?
Oxygen
Surfactant administration
Thermoregulation
ECMO
How is oxygen given to preterm babies with RDS?
CPAP
Mechanical ventilation
or high frequency ventilation
What is the role of ECMO in preterm babies with RDS?
Modified heart/lung machines that allows the baby’s lungs to rest/heal
What are two complications of respiratory distress in preterm babies?
Retinopathy of prematurity Bronchopulmonary dysplasia (BPD)
When do retinas reach maturity?
42-43 weeks
What causes retinopathy of premature babies?
When o2 is discontinued, hemorrhage and fibrosis may occur due to the vasoconstriction of o2
How long are babies with bronchopulmonary dysplasia on mechanical ventilation?
Greater than 14 days
What is bronchopulmonary dysplasia?
a condition that involves inflammation, architectural disruption, and disordered or delayed development of the infant lung
What is the treatment for bronchopulmonary dysplasia?
O2
Fluid restriction
Nutrition
Steroids
What is the normal progression of bronchopulmonary dysplasia?
Progresses to normalization usually
What is the normal respiratory rate of an infant?
30-60 breath per minute
Babies use their __ __ to breathe
abdominal muscles
What are early signs of respiratory distress syndrome?
Flaring of the nares with expiratory gut
What are late signs of respiratory distress syndrome?
Retractions, apneas spells, seesaw breathing pattern
Change in color from pink to cyanotic (circumoroal and then general)
What 3 factors make preterm babies especially at risk for thermoregulation issues?
Lack of flexed posture for preserving heat
Very thin skin with capillaries close to surface
Lack of subq fat
What characteristics make normal babies subject to thermoregulation issues?
Large surface are to body ratio Decreased subq fat Greater water body content Immature skin leading to increased water evaporation and heat loss Can't shiver Altered skin blood flow
Respiratory distress syndrome occurs in babies primarily as a response to…
metabolic acidosis
What are 5 other issues that can cause respiratory distress syndrome in ALL babies?
Hypothermia Sepsis Hypoglycemia Asphyxia Meconium aspiration syndrome
What are 4 major symptoms of hypothermia?
Respiratory distress
Apnea
Hypoxemia
Metabolic acidosis
What are other signs of hypothermia in babies?
Acrocyanosis Cool, mottles, pale skin Transient hyperglycemia Bradycardia Tachypnea Restlessness Shallow irregular breaths Lethargy Hypotonia Feeble cry Poor feeding Poor weight gain
What are signs and symptoms of hyperthermia in babies?
Tachycardia Tachypnea Apnea Warm extremities Flushing Dehydration Lethargic Hypotonia Irritability Weak cry
What are potential causes of fetal hyperthermia?
Overheating Maternal fever Epidural anesthesia Phototherapy Infection CNS disorders Dehydration
What is the most important consequence of hyperthermia?
Respiratory distress
What are consequences of hyperthermia in infants?
Hypotension Dehydration Seizures Apnea Hypernatremia Respiratory distress
Why does hyperthermia result in hypotension and dehydration in the infant?
Results from increased insensible water loss
What is the management of hyperthermia in the infant?
Move away from heat source or lower air temperature in incubator
Frequent breast feeding to replace lost fluids
What are three factors that contribute to infants becoming septic?
Shortage of maternal immunoglobulins
Impaired ability to make antibodies
Compromised integumentary system (think skin, fragile capillaries)
What are signs/symptoms of sepsis in infants?
Temperature instability Lethargy Irritability Change in color Cardio instability GI problems Metabolic acidosis Repository distress
Because preterm babies will not perform the same in growth and development as their peers…
The age of all preemies is adjusted when development is evaluated
When are preterm babies usually discharged??
36-40 week post conception age
A preterm baby at 36-40 weeks should have head lag response…
Baby should raise head parallel to body when lift from a prone position
A preterm baby at 36-40 weeks should have the ability to cry…
vigorously when hungry
A preterm baby at 36-40 weeks should have an appropriate weight and pattern…
of growth curves
A preterm baby at 36-40 weeks should have neurologic responses appropriate for corrected age such as…
able to follow examiner with eyes
Intraventricular hemorrhage in preterm babies can be mild or include…
cerebral palsy
hydrocephalus
severe learning disabilities
death
Incidence of intraventricular hemorrhage is highest in which group?
Babies less than 1500 grams or less than 35 weeks
Increased risk for intraventricular hemorrhage
Birth trauma
Decreased clotting factors
What are common symptoms of intraventricular hemorrhage?
Seziures, posturing, coma, or decreased consciousness. Also respiratory distress and bulging fontanel
What are 3 conditions necrotizing enterocolitis is associated with?
Intestinal ischemia due to hypoxia
Bacterial colonization of gut
Enteral feedings (versus breast feeding)
10% of all low birth weight babies will have __ __
necrotizing enterocolitis
What percentage of babies with necrotizing enterocolitis are preemies?
More than 90%
What is the mortality rate of necrotizing enterocolitis?
30%
When does necrotizing enterocolitis occur?
Usually within 1-3 days after birth but can take up to 30 days
How is necrotizing enterocolitis treated?
Surgery NPO TPN ABX May have bowel transplant if severe
What are maternal lifestyle factors that contribute to small gestational age?
Poor weight gain
Drugs
Alcohol abuse
What are maternal disease factors that contribute to small gestational age?
Hypertension
Preeclampsia
What are environmental factor can contribute to SGA?
Teratogens
What placental factor can contribute to SGA?
Aging due to post maturity
What fetal factors contribute to SGA?
Infections
Chromosomal abnormalities
What fetal factors contribute to large gestational age?
Male neonates
Beckwith-Wiedemann syndrome
What is Beckwith-Wiedemann syndrome?
Genetic abnormality that causes overgrowth syndrome
What maternal health factors can contribute to LGA?
Multiparous
Excessive weight gain
Erythroblastosis fetalis
DM
Diabetes in pregnancy often results in…
Macrosomia
What race of women are more at risk for having LGA baby?
Hispanic
What is symmetric IUGR caused by?
Long-term maternal conditions
How is IUGR diagnosed?
On ultrasound
What does IUGR symmetric affect?
Growth in size of organs, weight, length, and head circumference
What causes asymmetric IUGR?
Acute compromise of uretoplacental blood flow
Asymmetric IUGR is not present before…
the third trimester
__ __ is usually spared in asymmetric IUGR
Head growth
What are the parameters of asymmetric IUGR?
Birth weight SGA
Length and head circumference AGA
What are 9 complications of SGA or IUGR
Hypoxia Meconium aspiration syndrome Hypothermia Hypoglycemia Polycythemia Congenital malformations intrauterine infections Continued growth difficulties Cognitive difficulties
What are 11 complications of LGA or post maturity?
CPD Hypoglycemia Polycythemia Hypocalcemia Hyperviscosity Hyperbilirubinemia MAS Seizures Cold stress RDS Birth defect
What is meconium aspiration syndrome?
When fetus becomes hypoxic it causes relaxation of anal sphincter and meconium is released. Reflex gasping causes meconium to enter fetal lungs obstructing breathing after birth
What is a potential neural tube defect?
Anencephaly
Spina bifida
What is hydrocephalus?
Accumulation of CSF in subdural or subarachnoid space caused by overproduction or reduced reabsorption of CSF
What types of spina bifida can be seen from outside the baby?
Meningocele
Myelomeningocele
What is the greatest immediate risk of cleft lip or palate?
Aspiration during feedings
When does imperforate anus occur in development?
5-7th week
Half of babies with anorectal malformations have other abnormalities such as…
Kidney tract problems Reproductive Spinal Tracheal esophageal fistula Limb defects (forearm) Down syndrome
Most babies with an anorectal malformation will require..
surgery
What is clubfoot?
Tendons connecting the muscles to the bones are shorter than usual
How is clubfoot treated?
Usually without surgery using casting or braces to realign ankles
What is developmental dislocation of the hip? DDH
hip joint not formed fully, ball is loose in socket
How is DDH treated?
Plavik harness for 6-12 weeks. If unsuccessful surgery
What are symptoms of DDH?
Legs different lengths
Uneven skin folds of the thigh
Less mobility or flexibility on one side
What are risk factors for DDH?
Girls First born children Breech (especially with feet by shoulders) Family history Oligohydramnios
What percentage of pregnancies are complicated by substance abuse?
15%
What are barriers to treatment for pregnant women who abuse drugs?
Social stigma Guilt Long wait lists Labelling Criminal prosecution Fear of losing custody of their children
What at the the most commonly abused substances during pregnancy?
Smoking
Alcohol
Cocaine
Opioids
Smoking during pregnancy is associated with…
LBW IUGR Placenta previa Placental abruption PPROM Ectopic pregnancy SIDS
Drinking while pregnant is associated with…
Cognitive impairment
Issues with juvenile delinquency
Cognitive anomalies
Using cocaine while pregnant is associated with…
Miscarriage Preterm labor Placental abruption Stillbirth Birth defects
Abusing opioids while pregnant is associated with…
Neonatal abstinence syndrome
Opioids rapidly…
cross the placenta
What are the symptoms of NAS?
Irritability, sleep disorders, feeding problems that persist for weeks
What are complications of NAS?
Respiratory distress Jaundice Congenital anomalies IUGR Behavioral abnormalities Withdrawal
What is the modified Finnegan Neonatal Abstinence score sheet?
Assessment too that scores severity of withdrawal from opioids
What is included in the Finngan Neonatal Abstinence score sheet?
21 most frequently observed symptoms given a score
When should the nurse use the Finnegan Neonatal Abstinence score sheet?
Two hours after birth to establish a baseline then every 4 hours after each feeding until the infant is ad lib
If the infant scores an 8 or greater on the Finnegan Neonatal Abstinence score sheet, what should the nurse do?
Score every 2 hours until NAS medication started, then every 4 hours or after every feeding
When are ad lib infants scored using the neonatal abstinence score sheet?
After every feeding
What is the initial treatment of a baby born with NAS?
Supportive- skin to skin Safe swaddling Gentle waking Quiet minimal stimulation Low lighting Calm music Massage therapy
What are nursing interventions for a baby born with NAS?
Supportive care
Cluster care
Encourage parental involvement
Continue breast feeding
Mothers on methadone or buprenorphine should be encourage to…
continue breastfeeding
Mothers who are still using opioids still continue to breast feed because…
It can delay the onset and decrease the severity of withdrawal symptoms as well as decrease the need for pharmacological treatment
What are the most common first line medications used to treat NAS?
Morphine and methadone
Which is better, oral or sublingual morphine?
SL, linked to shorter hospital stays
What is the discharge criteria for infants born with NAS?
Be off all NAS-related medications
Continue to score for 72 hours
