Reproduction: Complicated Newborn Flashcards
What places a newborn at risk for complications?
- low socioeconomic level of the mother
- limited access to health care
- no prenatal care
- Exposure to environmental dangers
- Preexisting maternal conditions
- Maternal factors
- Medical conditions, complications
- complications of pregnancy
Birth of at-risk newborn may be anticipated by:
- the course of labor, birth unpredictable
- newborn classification, mortality risk tool
- Potential birth injuries
- Previous identification of congenital anomalies
When is an infant considered preterm?
When it is born less than 37 completed weeks
What are some growth-related complications?
- small for gestational age
- very small for gestational age
- Large for gestational age
- Intrauterine growth restriction
What are some birth-related complications?
- asphyxia
- respiratory distress
- transient tachypnea
- Meconium aspiration
- cold stress
- Hypoglycemia
- Polycythemia
What are some conditions at birth that can cause complications?
- mother with diabetes
- Post-term newborn
- Prenatal substance abuse
- Mother with HIV/AIDS
- Congenital heart defects
- Phenylketonuria
- Prematurity
- Galactosemia
- homocystinuria
- choanal atresia
- trachoesophagela fistula
- diaphragmatic hernia
- omphalocele and myelomeningocele
- gastroschisis
- prune belly syndrome
- imperforate anus
- congenital hydrocephalus
- maple syrup urine disease
What is Choanal Atresia?
Congenital narrowing of the back of the nasal cavity that causes difficulty breathing
What nursing assessments are needed for Choanal Atresia?
- Look for signs of respiratory distress (cyanosis and restrictions at rest)
- Noisy respirations
- Difficulty breathing during feeding (obligatory nose breathers)
- Obstruction by thick mucous
What are the goals and interventions for choanal atresia?
- Assess patency of nares
- listen for breath sounds while holding baby’s mouth closed and alternately compressing each nostril
- Assist with passing a catheter through each naris to confirm diagnosis
- Obtain ENT consult
- Maintain Respiratory Function
- Assist with taping airway in mouth to prevent respiratory distress
- Position with head elevated to improve air exchange
What is a Tracheoesophageal Fistula?
an abnormal connection between the esophagus and the trachea
What are the nursing assessments needed for Tracheoesophageal Fistula?
- hx of maternal polyhydramnios
- Excessive oral secretions
- constant drooling
- Abdominal distention beginning soon after birth
- Periodic chocking and cyanotic episodes
- Immediate regurgitation when feeding
- Aspiration of pharyngeal contents into the trachea
- Reflux of gastric contents into trachea leading to aspiration pneumonia
- Inability to pass NG tube
- S/S: Tachypnea, retractions, rhonchi, decreased breath sounds, cyanotic spells
What are the nursing goals and interventions for Tracheoesophageal Fistula?
- maintain respiratory status and prevent aspiration
- Elevate HOB 20-40 degrees (to prevent the reflux of GI contents)
- Keep baby calm (crying causes air to pass through fistula and to distend intestines)
- Maintain fluid and electrolyte balance
- begin broad-spectrum abx (secondary to risk of aspiration pneumonia)
- Provide parent education
- Keep parents informed
What is a Diaphragmatic Hernia?
A birth defect in which there is an abnormal opening in the diaphragm
What are the nursing assessments for a Diaphragmatic Hernia?
- difficulty initiating respirations secondary to hypoplastic lung on the affected side
- gasping respiration
- Nasal flaring and chest retractions
- Barrel chest and Asymmetric chest expansion
- Breath sounds may be diminished or absent, usually on the affected side
- Heart sounds displaced to the contralateral side
- Scaphoid abdomen (Abdomen is squeezed or depressed inward, bowel sounds may be heard in the thoracic cavity)
What are the goals and interventions for a Diaphragmatic Hernia?
- Do not ventilate with bag and mask (stomach and intestines will become air-filled and distended, further compressing the lungs)
- Maintain respiratory status (Give O2, prepare for intubation and ventilation, Considered a respiratory emergency)
- Initiate gastric decompression
- Place in high Semi-Fowler position (to use gravity to keep abdominal organs’ pressure off diaphragm)
- Turn onto the affected side (to allow unaffected lung expansion)
- Carry out interventions to alleviate respiratory and metabolic acidosis
What is Omphalocele?
A birth defect in which an infant’s intestine or other abdominal organs are outside of the body
What are the nursing assessments needed for Omphalocele?
- intestine or other abdominal organs are outside of the body because of a hole in the belly button (navel) area
- Encased in a protective transparent membrane
What are the nursing goals and interventions needed for Omphalocele?
- maintain hydration and temperature
- Place newborn in a sterile bag up to and covering the defect
- Obtain surgical consult
- Initiate decompression
- Position to prevent trauma to defect
- Administer broad spectrum antibiotics to prevent infection
What is Gastroschisis?
A birth defect in which an infant’s intestine are outside of the body
What are the nursing assessments needed for Gastroschisis?
- recognize that there is no protective covering around the intestines
- Intestines exposed to the caustic amniotic fluid
- Associated with intestinal atresia
- associated with malrotation (the intestines can become irritated, causing them to shorten, twist, or swell)
- Large amounts of evaporative fluid losses from the exposed bowel
What are the nursing goals and interventions for Gastroschisis?
- Maintain hydration and temp
- provide normal saline (for hypovolemia/fluid resuscitation)
- Place newborn in sterile bag up to the axilla in a side-lying position (to prevent trauma of the bowel)
- DO NOT COVER DEFECT WITH A WET SALINE GAUZE
- obtain surgical consult
- Initiate gastric decompression
- administer a broad-spectrum abx (to prevent infection of exposed bowel)
What is Prune Belly Syndrome?
a rare disorder characterized by partial or complete absence of the stomach (abdominal) muscles
What are the nursing assessments needed for Prune Belly Syndrome?
- recognize that there is a deficiency of the abdominal wall musculature
- abdomen is shapeless
- skin hangs loosely and is wrinkled in appearance
- Associated with urinary abnormalities
- Associated with Undescended testes (cryptorchidism)
What are the nursing goals and interventions for Prune Belly Syndrome?
- maintain respiratory status (may need to be immediately intubated and ventilated)
- Obtain surgical and urology consult
- Prevent trauma and infection
- Place a urinary catheter and monitor output
- Carry out interventions to alleviate respiratory and metabolic acidosis
- Keep parents updated and informed about prognosis
What is Myelomeningocele?
A defect of the backbone (spine) and spinal cord
What nursing assessments are needed for Myelomeningocele?
- Myelomeningocele directly connects to the subarachnoid space
- hydrocephalus often associated
- No response or varying response to sensation below the level of the defect
- May have constant dribbling of urine
- Incontinent or retention of stool
- Anal wink may or may not be present
What are the nursing goals and interventions for Myelomeningocele?
- prevent trauma and infection (position on abdomen or on side and restrain- prevents pressure and trauma to sac; administer broad-spectrum abx)
- Meticulously clean buttocks and genitals
- Cover with protective plastic wrap over sac (observe sac for oozing of fluid; DO NOT cover defect with wet saline gauze)
- Crede bladder to prevent urinary stasis
- Assess amount of sensation and movement below defect
- Obtain baseline occipital-frontal circumference measurements then measure head circumference daily
- check fontanelle for fullness and bulging
What is Imperforate Anus?
A defect that is present from birth. The opening to the anus is missing or blocked
What are the nursing assessments needed for Imperforate Anus?
- look for the inability to visualize rectal opening
- See that no meconium is passed
- Meconium is passed through a fistula or a malpositioned anus
- Gradual abdominal distension if no fistula present
What are the nursing goals and interventions for Imperforate Anus?
- inspect the perineal area for the presence of a fistula
- Initiate gastric decompression
- maintain fluid balance
- No rectal temperature
What is congenital Hydrocephalus?
A buildup of excess cerebrospinal fluid in the brain at birth
What are the nursing assessments for Hydrocephalus?
- enlarged or full fontanelles
- split or widened sutures
- “Setting sun” eyes
- Head circumference greater than 90% on growth chart
- Visibly distended scalp veins
- Behavioral stat changes: may become increasingly irritable or lethargic
What are the nursing goals and interventions needed for Hydrocephalus?
- assess presence of hydrocephalus
- Check fontanelle for bulging and sutures widening
- Obtain neurosurgery consult
- Assist with imaging studies: cranial ultrasound, CT scan, MRI
- Maintain skin integrity
- Change position frequently
- Use gel pillow under the head
What is Fetal Alcohol Syndrome?
a condition that results from alcohol exposure during the mother’s pregnancy
What assessments are needed for Fetal Alcohol Syndrome?
- abnormal structural development and CNS dysfunction (irritability, hypotonia, microcephaly and hyperactivity, and cognitive disability in childhood
- Growth deficiencies (restricted in regard to weight, length, and head circumferences)
- Distinctive facial abnormalities
- Associated anomalies
What distinctive facial abnormalities does a baby with Fetal Alcohol Syndrome have?
- epicanthal folds
- broad nasal bridge
- flattened midfacies
- short
- upturned or beaklike nose
- Abnormally small lower jaw
- thin upper lip and smooth groove on upper lip
What are the associated anomalies with Fetal Alcohol Syndrome?
Primarily septal and valvular defects, optic nerve hypoplasia, conductive and sensorineural hearing loss, kidneys, skeletal issues, especially congenital dislocated hips
What are the S/S of Fetal Alcohol Syndrome in newborns?
- sleeplessness and restlessness
- excessive arousal states
- inconsolable crying
- Abnormal reflexes
- Hyperactivity with little ability to maintain alertness and attentiveness to the environment
- Jitteriness
- Abdominal distention
- Exaggerated mouthing behaviors such as hyperactive rooting and increased nonnutritive sucking
- Seizures
- Signs and symptoms of withdrawal often appear within 3-12 hours and can last up to 18 months
What are the nursing goals and interventions for Fetal Alcohol Syndrome?
- Avoid heat loss
- Monitor VS and observe for evidence of seizure activity and respiratory distress
- Provide adequate nutrition
- Reduce environmental stimulation
How would a nurse provide adequate nutrition to a newborn with Fetal Alcohol Syndrome?
- require extra time and patience during feeding
- Inform alcohol-dependent mother that breastfeeding is not contraindicated, but that excessive alcohol consumption may intoxicate the newborn and inhibit the letdown reflex
What discharge care is needed for a newborn with Fetal Alcohol Syndrome?
- educate on possible long-term complications and treatments newborn may require
- Provide support for the parents and reinforce positive parenting
- Feeding: reduce stimulation; keep upright and burp often; feed as soon as there are signs of hunger; limit feeding time; small frequent amounts; use the same bottle, type of nipple, cloth, and bib every time
- Sleeping: crib should be in a quiet area with low lights; rock the baby gently (don’t overstimulate while rocking)
- Hygiene: calm atmosphere with diaper changes and bathing; low light, quiet
What are the risks to the fetus because of a drug-abusing mother?
- intrauterine asphyxia
- Intrauterine infection (STD’s, etc.)
- Intrauterine growth restriction (high correlation with substance abuse and poor maternal nutrition; diminished placental function)
- Low Apgar Scores (may be related to the intrauterine asphyxia or the medication the woman received during labor)
What are some common complications of a drug-exposed newborn?
- respiratory distress (heroin-addicted newborn frequently suffers; meconium-aspiration pneumonia; transient tachypnea)
- neonatal jaundice
- Behavioral abnormalities
- withdrawal
- Congenital anomalies and growth restriction
What behavioral abnormalities do babies exposed to drugs have?
- babies exposed to cocaine have a poor state organization
- Exhibit decreased interactive behaviors
- have difficulty moving through the various sleep and wake states
- Have problems attending to and actively engaging in auditory and visual stimuli
What type of congenital anomalies do babies of cocaine-addicted mothers exhibit?
congenital malformations involving bony skull defects, cardiac defects, IUGR, genitourinary defects, and a higher incidence of SIDS
What kind of anomalies do babies exposed to methamphetamines typically exhibit?
cleft lip and palate, cardiac anomalies, microcephaly, and low birth weight
What nursing management is needed for opioid dependency during pregnancy?
- early identification during prenatal period (determined by clinical indicators like maternal presentation, hx of substance use or abuse, medical hx, toxicology, mother’s last drug intake and dosage, assessing for congenital malformations
- Identifying the s/s of newborn withdrawal or neonatal abstinence syndrome
What are the CNS s/s of withdrawal in an infant?
- high-pitched cry
- hyperirritability, difficult to console, restlessness
- increased muscle tone
- exaggerated reflexes
- tremors, myoclonic jerks
- seizures
- sneezing, hiccups, yawning
- short, unquiet sleep
What are the GI s/s of withdrawal in an infant?
- disorganized, vigorous suck
- vomiting
- poor weight gain
- sensitive gag reflex
- Diarrhea
- Poor feeding (less than 15 mL on the first day of life; takes longer than 30 minutes per feeding)
What are the autonomic s/s of withdrawal in an infant?
- stuffy nose, sneezing
- yawning
- mottled
- Tachypnea (greater than 60 BPM when quiet)
- Sweating
- hyperthermia
What are the cutaneous s/s of withdrawal in an infant?
- excoriated buttocks, knees, and elbows
- facial scratches
- pressure-point abrasions
What planning and implementation are needed in the hospital with a newborn whose mother used drugs?
- perform neonatal abstinence scoring per policy
- monitor temp for hypothermia
- Monitor pulse, RR, and O2
- Provide small, frequent feedings, especially when vomiting and having diarrhea; side-lying or semi-Fowler’s to avoid possible aspiration
- Monitor weight gain pattern daily; monitor diarrhea frequency
- swaddle with hands near mouth to minimize injury
- Gentle vertical rocking
- protect baby’s face and extremities from excoriation by using mittens
- apply protective skin emollient to the groin area with each diaper change
- Place the newborn in a quiet dimly lit area of the nursery
- administer meds as ordered
What discharge teaching is needed for a newborn whose mother was a drug user?
- instruct parents to anticipate mild jitteriness and irritability in the newborn (may last from 6 days to 8 weeks depending on the initial severity of withdrawal)
- Newborns at higher risk for SIDS (sleep on back and home apnea monitoring is needed)
- teach feeding techniques, comforting measures, how to recognize newborn cues, and appropriate parenting responses
- Council parents regarding available resources such as support groups
- Council parents on the need for ongoing evaluation and follow-up care
What are some preventative strategies for HIV/AIDS in newborns?
- prenatal testing
- Antiretroviral therapy
- Viral load measurements
- Scheduled cesarean sections
- Early identification of babies with or at risk for HIV/AIDS
How is HIV spread to most newborns at risk?
Most HIV transmissions during the perinatal and newborn periods occur across the placental, across the amniotic membranes, or through breast milk or contaminated milk
What is the preferred test for HIV infection in newborns?
bDNA polymerase chain reaction (PCR) assay and HIV RNA assays
What do a positive bDNA PCR and HIV RNA assay mean by 48 hours of age?
Suggests in utero transmission, allowing early identification and treatment
What test for HIV is inappropriate for babies up to 18 months of age and why?
Enzyme-linked immunosorbent assay and Western Blot test; before 18 months of age babies do not form their own antibodies to HIV and you cannot distinguish between maternal and infant antibodies
What part of the infant should not be used for HIV testing at birth?
the umbilical cord blood because it can be contaminated with maternal blood leading to a false-positive result
How often should HIV testing be performed on an infant?
repeat blood work at 14-21 days, 1-2 months, and 4-6 months postnatal
What are the signs of HIV in the early infancy period?
- enlarged spleen and liver
- swollen glands
- Recurrent respiratory infections
- Rhinorrhea
- Interstitial pneumonia
- Recurring GI and urinary systems infections
- Persistent or recurrent oral candidiasis
- Lost of achieved developmental milestones
- Risk of acquiring Pneumocystis jirovecii pneumonia
What are the treatments for infants whose mothers have HIV/AIDS?
- AZT is started prophylactically
- If blood tests are positive National Institutes of Health recommends changing to a combination antiretroviral therapy
- Avoid breastfeeding
- A baseline CBC with differential and platelets is obtained as anemia is one of the side effects of AZT therapy
When are congenital heart defects most commonly seen?
In the first 6 days of life
What are some common congenital heart defects?
- Left ventricular outflow obstructions
- hypoplastic left heart
- Coarctation of the aorta
- Patent ductus arteriosus
- Transposition of the great vessels
- Tetralogy of Fallot
- Large ventricle septal defects or atrial septal defects
What are the manifestations of heart defects in newborns?
- cyanosis
- detectable heart murmur
- Congestive heart failure symptoms
What nursing management is needed for congenital heart defects?
- Primary goal is to identify cardiac defects early
- Initiate referral to the healthcare provider
- care of preoperative and postoperative newborn
- After the baby is stabilized decisions need to be made regarding ongoing care
- Education regarding ongoing care
- Provide emotional support
- Genetic counseling for some
When is an infant considered preterm?
when they are born before 37 weeks gestation
What are some critical factors regarding the respiratory and cardiac physiology of a premature newborn?
- unable to produce adequate amounts of surfactant
- Incomplete muscular coat of pulmonary blood vessels
- Ductus arteriosus may remain open
What immunological factors are a risk for a premature newborn?
- greater risk for infection than term newborns
- IgG immunoglobulin deficiency
- skin easy excoriated
Why is thermoregulation an issue for premature babies?
- availability of glycogen
- amount of brown fat
- not able to maintain thermoregulation
What are the 5 factors that increase heat loss in babies?
- the higher ratio of body surface area to body weight
- little subcutaneous fat
- Thinner, more permeable skin
- Posture influences heat loss
- Decreased ability to vasoconstrict
What are some GI problems in premature newborns?
- aspiration risk
- difficulty meeting high caloric, fluid needs
- Limited ability to convert essential amino acids
- Inability to handle formula protein
- Difficulty absorbing saturated fats
- Initial difficulty with lactose digestion
- Calcium, phosphorus deficiency may exist
- Increased metabolic rate and oxygen requirements
- Feeding intolerance, necrotizing enterocolitis
What are some issues with the renal system in premature babies?
- Kidney immaturity (problems managing F&E imbalance; glomerular filtration rate low)
- limited ability to concentrate urine
- kidneys excrete glucose at a lower serum level
- Buffering capacity reduced
- Immaturity affects the ability to excrete drugs
What nutritional requirements are needed for a premature baby?
- Early feedings valuable
- Oral caloric intake needs: 95-130 kcal/day
- Feeding regimens based on weight/capacity
- Higher calorie and protein formula/supplements
- Intake adequate with weight gain of 20-30 g/day
What fluid requirements are needed for a premature baby?
- calculation based on weight/postnatal age
- minimize fluid losses
- daily weights
What may a premature infant need Gavage feeding?
- if <34 weeks
- ill
- ventilator dependent
- Adjunct to nipple feeding if losing weight
- serves to “prime” premature infant’s intestinal tract
- Early gavage as a supplement to parenteral
What are some long-term needs for premature infants?
- motor delays/sensory disability
- higher mortality rate in the first year
- retinopathy of prematurity
- Bronchopulmonary dysplasia
- speech defects
- neurological defects
- Auditory defects
What are some complications of prematurity?
- Apnea of prematurity
- Patent ductus arteriosus
- Respiratory distress syndrome
- Intraventricular hemorrhage
- Anemia of prematurity
What are some interventions for a nurse to maintain respiratory function?
- suction as needed
- elevate the head to maintain airway/ avoid hyperextension of the neck
- Monitor HR/RR
- Give O2 if needed
- consider respiratory function before and during feedings
What are the s/s of respiratory distress?
- cyanosis
- retractions
- nasal flaring
- presence of rales/rhonchi
- Tachypnea
- Expiratory grunting
- Apneic episodes
- Diminished air entry
What are some nursing interventions to minimize heat loss?
- monitor ambient temperature of the room
- promote skin-to-skin contact between the mother and child
- warm/humidified oxygen
- double-walled incubator/heat shield
- Avoid placing baby on cold surfaces
- Keep warmers/incubators away from drafts
- open incubator portholes only when necessary
- Use skin probe to monitor baby’s skin temp
- Warm formula/stored breast milk before feed
- Reflector patch over skin temperature probe
- keep them clothed and swaddled
What are some signs of dehydration in infants?
- sunken fontanelles
- loss of weight
- poor skin turgor
- Dry oral mucous membranes
- Decreased urine output
- Increased specific gravity
What are some signs of feeding intolerance?
- increasing gastric residuals
- Abdominal distention
- Guaiac-positive stools
- Vomiting
- Diarrhea/water-loss stools
What are some signs of the readiness for oral feedings in infants?
- strong gag reflex
- presence of nonnutritive sucking
- rooting behavior
What are some interventions to promote nutrition and prevent fatigue during feeding?
- Measure abdominal girth
- auscultate abdomen for bowel sounds
- check residual before feeding
- Feed by gavage if ill or easily fatigued
What are some nursing interventions to prevent infection?
- nurse responsible for minimizing exposure
- Strict hand hygiene
- Separate equipment for each infant
- 2-3 minute scrub for staff members
- Nurse may be first to identify subtle clinical signs
What are some interventions to promote parent-infant attachment?
- promote positive feelings
- weekly card with footprint, weight, and length
- Give parents the number of the nursery, NICU, and names of staff members
- encourage visits from family members
- Early involvement of parents in care/decisions
- Parents need education
- Provide opportunities for parents to touch, hold, talk to, and care for their baby
What are some ways to decrease detrimental stimuli in the NICU?
- replace alarms with lights to lower noise levels
- Silence alarms quickly
- Keep conversations away from infants’ bedsides
- Use a dimmer switch to shield eyes from lights
- Plan care to decrease disturbing baby
What are some other interventions to promote developmentally supportive care?
- Use containment measure when turning
- touch gently, avoid sudden postural changes
- Promote self-consoling/soothing activities
- Stimulate intrauterine environment (sheepskin, approved water beds)
- Promote nonnutritive sucking
- Provide objects for infants to grasp
- Teach parents how to read behavioral cues
How much should infants’ head circumferences grow per week?
1 cm per week
