Nursing mgmt of the newborn w/ special needs and risks

Question 1

Nursing mgmt for SGA/LGA/hypoglycemia

Answer 1

-If oral feedings not accepted, give buccal dextrose gel or IV w/ 10% dextrose in water to maintain glucose > 40
-Weight baby daily

Question 2

Polycythemia mgmt

Answer 2

-Venous hct > 65% and hgb > 20
-Common in SGA newborns
-s/s: jitteriness, jaundice, seizures, ruddy skin, cyanosis
-If as/s –> fluids
-If s/s –> partial plasma exchange

Question 3

Premature body systems

Answer 3

-Respiratory: low surfactant, atelectasis, small passages
-CV: low O2, congenital anomalies
-GI: weak reflexes, hypoxia, small stomach
-Renal: low GFR, drug toxicity
-Immune: susceptible to infection, low IgG, thin skin
-CNS: susceptible to injury, low brown fat, hypoglycemia

Question 4

Premature nursing assessment

Answer 4

-< 5.5 lbs
-Scrawny appearance
-Head larger than chest
-Minimal fat
-Undescended testes
-Prominent vulva
-Plentiful lanugo
-Fused eyelids
-Matted scalp hair
-Few creases in palms and soles
-Breast and nipple not clearly delineated
-Abundant vernix caseosa

Question 5

Nursing mgmt: oxygenation

Answer 5

-Asphyxia: newborns who fail to establish adequate respirations after birth (perinatal acidosis), causes brain injury
-Hypoxia, hypercarbia, acidosis, hypoxia
-If after 15 sec of tactile stimulation w/o effective respirations or increase in HR above 100 BPM, infant should be resuscitated
-Elevate head slightly
-Encourage kangaroo care
-Neutral thermal environment
-Equipment for resuscitation: vacuum-suction, stethoscope, pulse ox, EPI, IV fluids, O2 tank, endotracheal tubes, laryngoscope, narcan

Question 6

ABCDs

Answer 6

-Airway: place head in sniffing position, suction mouth then nose
-Breathing: use PPV for apnea or HR > 100, ventilate
-Circulation: start compressions if HR < 60 after 30 sec of PPV (compression to ventilation ratio of 3:1)
-Drugs: give EPI if HR < 60 after 30 sec of compressions and ventilation

Question 7

Nursing mgmt: promoting nutrition

Answer 7

-Orally, enterally, or parenterally via IV infusion
-Born after 34 weeks can feed orally
-Born before 34 weeks need alternative method
-Gavage feedings for compromised newborns to allow them to rest during feedings
-Sunken fontanelles = dehydration
-Bulging fontanelles = overhydration

Question 8

Nursing mgmt: preventing infection

Answer 8

-Early onset = within 1st week, blood or CSF dx test
-Late onset = after 1st week

Question 9

Nursing mgmt: appropriate stimulation

Answer 9

-Overstimulated by noise, lights, excessive handling, alarms, procedures
-Flay hands and cover face w/ arms
-HR and RR decrease d/t stress (apnea may follow)

Question 10

Nursing mgmt: pain

Answer 10

-s/s: high-pitched cry, O2 low, increased vitals, squirming, facial grimace
-Prevent noxious stimuli, pacifier, breastfeeding, skin-to-skin, swaddling, heat sources, therapeutic touch
-Morphine, ketamine, fentanyl are used for severe pain
-NSAIDs for mild pain

Question 11

Discharge planning

Answer 11

-Education: involvement during NICU
-Eval of unresolved problems: follow-ups
-Primary care: screening tests, immunizations, funduscopic exam for ROP, hematologic status eval
-Home care plan: equipment, ability to care for infant, emergency plan, financial resources, med admin education

Question 12

Postterm newborn: nursing assessment

Answer 12

-Dry, peeling skin
-Absence of vernix caseosa or lanugo
-Long, thin extremities
-Creases cover palms and soles
-Very alert
-Abundant scalp hair
-Thin umbilical cord
-Long fingernails
-Meconium-stained skin and fingernails

Question 13

Postterm newborn: nursing mgmt

Answer 13

-Risk for asphyxia
-IV dextrose 10% and early feedings
-Prevent neurodevelopmental delays
-Adequate hydration

Question 14

Assisting parents w/ coping w/ perinatal loss: before death

Answer 14

-Respect variations in cultural and spiritual needs
-Call hospital clergy
-Encourage methods to maintain physical health
-Early care to reduce family stress
-Assess support network

Question 15

Assisting parents w/ coping w/ perinatal loss: after death

Answer 15

-Help family accept reality of situation
-Acknowledge their grief
-Provide w/ info abt cause of death
-Allow them to hold newborn

Question 16

Assisting parents w/ coping w/ perinatal loss: release of newborn’s body

Answer 16

-Encourage family to have a funeral service
-Suggest to plant tree or flowers to remember infant
-Provide info abt local support groups
-Present. info abt impact on future pregnancies

Question 17

Types of disorders

Answer 17

-Congenital: structural, fxnal, metabolic abnormalities which are present at birth, usually are chromosomal issues (eg: heart defects, neural tube defects, down syndrome)

Question 18

Acquired disorders

Answer 18

-Occur at or soon after birth, result from conditions experienced by mother during her pregnancy or at birth
-Not passed genetically, obtained after birth by rxn to environmental influences outside of body
-Ex: DM, infection, substance abuse, RDS, retinopathy of prematurity (ROP), birth trauma, hyperbilirubinemia

Question 19

Acquired disorders: asphyxia

Answer 19

-Profound acidemia
-Oxygenation is delayed
-Impaired gas exchange –> hypoxemia and hypercarbia –> metabolic acidosis
-Resuscitation and ventilation are needed
-Risks: trauma, sepsis, malformation, hypovolemic shock, meds
-Dx: blood toxicology screen (detects drugs)
-Mgmt: wall suction, O2, warmer, O2 leads, surgical blue towels, endo tube, narcan

Question 20

Acquired disorders: transient tachypnea

Answer 20

-Mild degree of respiratory distress
-d/t edema
-Inability of lungs to clear liquid
-s/s rarely last over 3 days
-s/s: grunting, retractions, diminished breath sounds, tachypnea, labored breathing, nasal flaring, crackles, barrel-shaped chest, hyperventilation
-6 hours of age w/ RR as high as 100-140 bpm
-Dx: mild symmetric lung hyperaeration; prominent perihilar interstitial marks and streaks
-Mgmt: O2, IV fluids until RR low enough for oral feeding

Question 21

Acquired disorders: RDS

Answer 21

-Deficiency in surfactant
-s/s: grunting, shallow breathing, nasal flaring, retractions, seesaw respirations, cyanosis, crackles, hypoventilation
-s/s only last 3 days
-Dx: hyaline membranes produce glassy appearance in lung membranes on x-ray
-Tx: surfactant given at 2 then 4 hrs, dextrose for hypoglycemia, suctioning, vasopressors, abx
-Mgmt: PEEP, surfactant therapy, CPAP
-Chronic stress (trauma, drugs, meds) experienced by fetus in utero accelerates production of surfactant before 35th week GA –> decreased risk of RDS

Question 22

Acquired disorders: Meconium aspiration syndrome

Answer 22

-Newborn inhales particulate meconium mixed w/ amniotic fluid into the lungs while still in utero or when taking 1st breath after birth
-Inhaled meconium –> increased risk of infection
-Staining of amniotic fluid, nails, skin, umbilical cord
-s/s: barrel-shaped chest, tachypnea, grunting, retractions, cyanosis
-Dx: chest-ray shows hyperventilation, ABGs, patchy fuffy infiltrates
-Tx: suctioning mouth and nares at birth

Question 23

Acquired disorders: Persistent pulmonary HTN

Answer 23

-Echo shows R –> L extrapulmonary shunting of blood, severe hypoxemia and acidemia
-s/s: tachypnea within 12 hrs after birth, systolic ejection harsh sound
-Mgmt: neutral thermal environment, O2 via cannula or ventilation, ECMO for severe cases, immediate resuscitation after birth
-Almost any procedure (suctioning, weighing, changing diapers) can cause severe hypoxemia –> minimize exposure to stimulation

Question 24

Acquired disorders: Bronchopulmonary dysplasia/chronic lung disease

Answer 24

-Newborns w/ lung injury resulting in need for continued use of O2 after neonatal period
-Caused by high O2 exposure and prolonged ventilation
-Most common adverse pulmonary outcome of preterm birth
-Mgmt: bronchodilators, high calorie diet, CPAP, PEEP, intubation last resort, steroids to mother while pregnant, exogenous surfactant to newborn after birth
-Reduction: lower O2 levels, close patent ductus arteriosus early, monitor tidal volumes on ventilator, post nasal steroid therapy, administer stem cell therapy

Question 25

Acquired disorders: ROP

Answer 25

-Potentially blinding retinal vascular eye disease
-Can cause vitreous hemorrhage and retinal detachment, causing visual impairment and blindness
-Exposure to high O2 –> retinal vasoconstriction –> abnormal blood vessels develop –> scar tissue
-5 stages
-Criteria: severity, location by zones, extent of retinal circumference
-Tx: prevention, severe = laser photocoagulation or cryotherapy, laser ablation is most common, injection of avastin or lucentis
-Mgmt: O2 sat mid 80s-90s, dim lights
-Any newborn w/ BW < 15000 g or born < 28 weeks should see opthalmologist within 4-6 weeks after birth

Question 26

Acquired disorders: Periventricular-Intraventricular hemorrhage

Answer 26

-aka PVH-IVH
-Bleeding originating in subependymal germinal matrix region of brain
-Causes brain injury
-Elevated midline head position of 30+ degree for 1st 4 days decreases likelihood of developing
-Dx: ultrasound, CT, MRI
-s/s: weak sucking, bulging fontanelle, hypotonia
-Mgmt: admin fluids slowly, correct anemia and hypotension w/ fluids, keep newborn in flexed position w/ head elevated, reduce stimulation

Question 27

Acquired disorders: Necrotizing enterocolitis

Answer 27

-Caused by bacterial invasion into GI wall –> inflammation
-Most common serious GI disorder in preemies
-Reduce risk w/ abx, parenteral fluids, breastmilk, corticosteroids, probiotics
-s/s: blood stools, feeding intolerance, bowel perforation w/ free air on x-ray, sepsis shock signs
-Dx: x-ray (gas patterns, thick walls,), CBC, ABGs
-Mgmt: fluids, TPN, abx, bowel rest, resolves after stopping oral feedings, gastric decompression

Question 28

Acquired disorders: Infant of a diabetic mother

Answer 28

-Poor glycemic control during 1st trimester –> major reason for congenital malformations
-Causes baby to be LGA or SGA, have RDS, hypoglycemic, hypocalcemic, hypomagnesemic, polycythemic, hyperbilirubinemic
-s/s: rosy cheeks and skin, short neck, buffalo hump, massive shoulders, distended abdomen, excessive fat, cephalohematoma, skull fxs, facial nerve paralysis, bruising
-Hypoglycemia: < 40 within 4 hrs, < 45 within 4-24 hrs
-Mgmt: correct electrolyte imbalances, early feedings, IV glucose, reduce stimuli, rest periods, IV Ca gluconate

Question 29

Acquired disorders: Birth injury

Answer 29

-Impairment of body or structure d/t adverse influence at birth such as forceps deliveries
-Usually skull, brain and SC
-C-section helped w/ decline in birth injuries

Question 30

Acquired disorders: Newborns of mothers who abuse substances

Answer 30

-Intrauterine growth restriction (IUGR), prematurity, neuro and behavioral problems in childhood, withdrawal, FASD, ARBDs, FAEs
-s/s: hypoxias hypoxia in utero

Question 31

Acquired disorders: NAS

Answer 31

-Opioids most common
-Tx: opioid replacement therapy w/ morphine or methadone, soothing techniques, no stimuli
-Can progress to seizures, irregular sleep, GI dysfxn (poor feeding, excessive sucking, loose stools, high-pitched cry, hyperreflexia)
-Cocaine exposed newborns are fussy, irritable, inconsolable, poor sucking and swallowing

Question 32

WITHDRAWAL acronym

Answer 32

-Assess for s/s in NAS
-Wakefulness
-Irritable
-Temperature variation
-Hyperactivity
-Diarrhea, diaphoresis
-Respiratory distress
-Apneic attacks
-Weight loss
-Alkalosis
-Lacrimation

Question 33

Caring for newborn at home

Answer 33

-Head elevated to prevent choking
-To aid sucking and swallowing during feeding, position chin down and support with hands
-Place baby on back when sleeping
-Keep bulb syringe by to suction mouth
-Cluster newborn care to prevent overstimulation
-If fussy: wrap in blanket and gently rock, take baby for car ride, soothing music and dance w/ them, wind up swing
-To help sleep: bath w/ massage prior to bed, feed before bed, if needs are met and they are in bed, allow them to cry

Question 34

Acquired disorders: Hyperbilirubinemia

Answer 34

-Physiologic more common
-Yellowing of skin and eyes
-Bilirubin > 5 mg/dL
-Breastfed newborn have peak bilirubin by 4th day of life
-Early onset breastfeeding jaundice is associated w/ ineffective breastfeeding practices
-Significant jaundice in newborn < 24 hrs should be assessed immediately
-Dx: direct coombs test (positive = RBCs coated w/ antibodies), Hgb concentration (anemia), blood type (Rh status), total serum protein, reticulocyte count
-Mgmt: ensure frequent feedings, phototherapy (cover genitals and eyes), assess temp, monitor stool (green, loose stools)

Question 35

Caring for newborn receiving home phototherapy

Answer 35

-Inspect skin, eyes, mucous membranes
-Keep lights 12-30 in above
-Cover eyes w/ patches or cotton balls and gauze
-Keep undressed except for diaper area (fold diaper down before navel)
-Turn q2h
-Remove from lights only for feeding
-Stools should be loose and green as bilirubin is broken down
-Keep skin dry and prevent irritation

Question 36

Acquired disorders: Neonatal sepsis

Answer 36

-Bacteremia w/ systemic s/s of infection in 1st month
-Early onset: birth - 1 week, from mother
-Late onset: 1 week - 28 days, from family members or environment
-Intrauterine infections: congenital infection acquired in utero
-Dx: CRP for inflammation, chest x-ray for infectious processes, CSF and urine culture for infection type
-Mgmt: abx for 7-21 says if cultures are positive, frequent position changes, aseptic technique, s/s of organ dysfxn, sepsis tx (fluids and vasopressors, O2, cultures, abx)

Question 37

Congenital conditions

Answer 37

-Come from genetic disorders, exposure to teratogens, sporadic and unknown causes
-Present at birth

Question 38

Congenital conditions: congenital heart disease

Answer 38

-Structural defect involving heart and/or great vessels
-Septal wall defect, obstruction defect, cyanotic heart lesions, defects of great vessels
-CCHD is group of 7 most severe congenital heart disease: coarctation of aorta, transposition of great arteries, hypoplastic L heart syndrome, total anomalous pulmonary venous return, single ventricular defects, TOF, truncus arteriosus
-Dx: prenatal ultrasound
-TX: mild = no tx, severe = surgery

Question 39

Congenital conditions: neural tube defects

Answer 39

-CNS structural defects
-Involve spine (spina bifida, meningocele, myelomeningocele) and brain (anencephaly)
-Neural tube fails to close during early embryogenesis
-Closed (covered by skin) or open (exposed)
-Dx: alpha-fetoprotein elevated during pregnancy
-Mgmt: look for CSF leakage, aseptic technique, avoid trauma to sac (prone or side-lying), diaper over sac, sterile dressing, clean genitals, provide warmth

Question 40

Congenital conditions: anencephaly

Answer 40

-Most severe NTD
-Cerebral hemispheres partially missing
-Alpha-fetoprotein levels elevated in 1st trimester
-Born stillborn, blind, deaf, or unconscious
-If born alive, die within few days

Question 41

Congenital conditions: spina bifida occulta

Answer 41

-Caudal defects below T12
-Spine doesn’t close properly
-Leading cause of infantile paralysis
-Missing vertebrae, not visible externally
-Hairy patch, dermal sinus tract, dimple, hemangioma, lipoma may be noted in area
-Rarely causes disability

Question 42

Congenital conditions: spina bifida cystica

Answer 42

-Meningocele: less severe, herniation of meninges and spinal fluid protrudes, as/s or paralysis w/ GI dysfxn, surgery needed
-Myelomeningocele: more severe, spinal cord and nerve roots herniate into sac, most common, affects entire CNS, can occur any on spine but most common in lower lumbar or sacrum, causing paralysis w/ GI dysfxn and hydrocephalus, increased risk for latex allergy d/t surgery

Question 43

Congenital conditions: microcephaly

Answer 43

-Small brain is located within a normal-sized cranium
-Failure to grow
-Dx: CT, MRI
-Tx: no known tx, supportive care
-Causes neurological impairment

Question 44

Congenital conditions: hydrocephalus

Answer 44

-Increase in CSF in ventricles of brain d/t overproduction or impaired circulation and absorption
-Increases ICP and leads to brain damage
-CSF production of 400-600 mL/day, but CSF doesn’t drain
-Tx: surgical placement of shunt system, ETC is alternative (keeps CSF within brain and SC)
-Dx: MRI, CT
-s/s: bulging fontanelles, setting sun eyes
-Mgmt: sheepskin or waterbed or egg crate mattress, position head to not lie on shunt area

Question 45

Congenital conditions: choanal atresia

Answer 45

-Malformation of upper airway that involves narrowing of nasal airway d/t membranous or bony tissue
-Respiratory distress
-Inability to pass suction catheter thru nose into pharynx is highly suggestive
-Dx: CT, endoscopy
-Tx: surgery to remove obstruction, will fully recover

Question 46

Congenital conditions: congenital diaphragmatic hernia (CDH)

Answer 46

-Severe anomaly of failure in development of diaphragm that results in abnormal insertion onto inner chest wall
-Tx of severe respiratory distress and pulmonary HTN
-Resuscitation immediately
-s/s: barrel-shaped chest, absent breath sounds, bowel sounds heard in chest
-Dx: x-ray or ultrasound (considered when polyhydramnios is present) shows air-filled bowel in chest
-Mgmt: resuscitation, surgery, ventilation, admin surfactant, steroids, and inhaled nitric oxide, minimize stimuli

Question 47

Congenital conditions: cleft life and palate

Answer 47

-Most common congenital malformation of head and neck
-Cleft lip: fissure in opening of lip
-Cleft palate: fissure in opening of roof of mouth
-Unilateral more common than bilateral
-Tx: surgery btwn 6-12 weeks
-Assess: maternal use of illicit drugs or phenytoin
-s/s: restricted facial growth, hearing problems, dental problems, speech anomalies, swallowing and feeding difficulties, ear infection
-Milk flow during feeding requires negative pressure and sucking pressure, use special nipples, squeezable bottles, and feeders
-Mgmt: breastfeed in upright position and burp less frequently, limit feeding sessions

Question 48

Congenital conditions: esophageal atresia (EA) and tracheoesophageal fistula (TEF)

Answer 48

-Esophagus and trachea are not connected
-Respiratory distress
-Most common fistula btwn distal esophagus and trachea
-s/s: rattling respirations, excessive salivation and drooling, coughing, choking, cyanosis (3 C’s)
-Dx: x-ray, ultrasound, MRI (gastric tube is coiled in upper esophageal pouch w/ air in GI tract = fistula)
-Preop care: elevate head, maintain orogastric tube, have O2 equipment ready, minimize crying
-Postop care: TPN, abx, before initiating oral feedings, an esophagram is ordered

Question 49

Congenital conditions: omphalocele and gastroschisis

Answer 49

-Anomalies of anterior abdominal wall at or near umbilicus
-Omphalocele: defect of umbilical ring that allows evisceration of abdominal contents into external peritoneal sac
-Gastroschisis: full-thickness defect of abdominal wall that occurs in L or R of umbilicus that exposes the extruded bowel to amniotic fluid (no sac protecting organs), despite surgery, feeding intolerance, short bowel syndrome, intestinal stricture, bowel obstruction, FTT occur
-s/s: protrusion of abdomen, evidence of sac, inspect sac for organs/twisting of organs such as intestines and liver
-Mgmt: airway stabilization, sterile wrapping of bowel, IV access, sterile technique, orogastric tube

Question 50

Congenital conditions: imperforate anus

Answer 50

-Malformation of anorectal area (rectum may end in blind pouch that doesn’t connect to colon, fistulas)
-Tx: surgery for high type (colostomy w/ corrective surgery), surgery for low type (closure of fistula, creation of anal opening)
-Assessment: observe for meconium if anal opening exists, urine output, intestinal obstruction
-Mgmt: gastric decompression, abx, pain relief, stoma care

Question 51

Congenital conditions: hypospadias

Answer 51

-Common malformation of penis (abnormal positioning of urinary meatus on underside of penis)
-Scrotal and testicular anomalies are often associated (undescended testes)
-Degree depends on location of opening
-Accompanied by downward bowing of penis (chordee)
-May causes urination, erection, and fertility problems in adulthood
-Tx: surgery

Question 51

Congenital conditions: epispadias

Answer 51

-Usually in boys
-Boys: urethra opens on top or side rather than tip of penis
-Girls: urinary meatus located btwn clitoris and labia
-Tx: surgery, boys shouldn’t be circumcised

Question 52

Congenital conditions: bladder exstrophy

Answer 52

-Bladder protrudes into abdominal wall
-All males have associated epispadias
-Initial bladder closure completed within 48 hrs after birth
-Admin abx, inspect skin, maintain modified brant traction for immobilization after surgery, admin antispasmodics, analgesics, sedatives, care of urinary catheter

Question 53

Congenital conditions:
Congenital clubfoot

Answer 53

-Talipes equinovarus
-More common in men
-Bilateral in most cases
-Excessively turned-in foot
-Components: inversion and adduction of forefoot, inversion of heel and hindfoot, limitation of extension of ankle, internal rotation of leg
-Tx: casts then surgery

Question 54

Congenital conditions: developmental dysplasia of the hip (DDH)

Answer 54

-Abnormal growth of hip
-Not recognized at newborn exam, must be monitored at doctor visits thruout 1st year
-Tx: braces, surgery, pavlik harness