week 3 Chapter17 high risk neonatal nursing care Flashcards

1
Q

Two most important predictors of an infants health and survival

A

Period of gestation and birth weight

prematurity and low birth weight are second leading causes of infant death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Prematurity classifications

A

Prematurity is classified as:
● Very premature: Neonates born at less than 32 weeks’ gestation (Fig. 17–1).
● Premature: Neonates born between 32 and 34 weeks’ gestation.
● Late premature: Neonates born between 34 and 37 weeks’ gestation.

The percentage of premature births based on mother’s race are:
● Non-Hispanic black: 13.4%.
● American Indian or Alaska Native: 10.5%.
● Hispanic: 9.1%.
● Non-Hispanic white: 8.9%.
● Asian or Pacific Islander: 8.6% (Martin et al., 2017).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Classifications of birth weight

A

Prematurity is a primary reason for low birth weight. Classification of birth weight (regardless of gestational age) is as follows:

● Low birth weight: Less than 2,500 g at birth

● Very low birth weight: Less than 1,500 g at birth

● Extremely low birth weight: Less than 1,000 grams at birth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Common complications related to prematurity

A

Common complications related to prematurity are respiratory distress syndrome, retinopathy of prematurity, bronchopulmonary dysplasia, patent ductus arteriosus, periventricular-intraventricular hemorrhage, and necrotizing enterocolitis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Assessment findings:

Prematurity

A

● Gestational age by Ballard score is at or below 37 weeks.

● Physical characteristics vary based on gestational age (Fig. 17–2).

● Tone and flexion increase with greater gestational age. Early in gestation, resting tone and posture are hypotonic and extended.

● The skin is translucent, transparent, and red.

● Subcutaneous fat is decreased.

● Lanugo is present between 20 and 28 weeks’ gestation. At 28 weeks’ gestation, lanugo begins to disappear on the face and the front of the trunk.

● Creases on the anterior part of the foot are not present until 28 to 30 weeks. As gestation increases, plantar creases increase and spread toward the heel of the foot.

● Eyelids are fused in very preterm neonates. Eyelids open between 26 and 30 weeks’ gestation.

● Overriding sutures are common among premature, low-birth-weight neonates.

● The pinna of the ear is thin, soft, flat, and folded.
● The testes are not descended and are found in the inguinal canal.

● Tremors and jittery movement may be noted.

● The cry is weak.

● Reflexes may be diminished or absent.

● Immature suck, swallow, and breathing patterns are observed in very premature infants. These neonates may not be able to take adequate oral feedings.

● Apnea (cessation of breathing for 20 seconds or longer) or a shorter pause accompanied by bradycardia (heart rate less than 100 beats per minute [bpm]) are commonly observed (Eichenwald, 2016).

● Hypotension may occur among extremely low-birth-weight infants.

● Heart murmur may be present related to patent ductus arteriosus.

● Anemia is common, especially among very-low-birth-weight babies.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Non-modifiable risk factors for preterm labor and birth

A
Previous preterm birth
Multiple abortions
Race/ethnic group
Uterine/cervical anomaly
Multiple gestation
Polyhydramnios
Oligohydramnios
Pregnancy induced hypertension
Placenta previa (after 22 weeks)
Diethystilbestrol exposure
Short interval between pregnancies
abruptio placenta
Parity(0 or greater than 4)
Premature rupture of membranes
Bleeding in first trimester
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Treatable/modifiable risk factors for preterm labor and birth

A
Age at pregnancy younger than 17 or older than 34 unplanned pregnancy
single
Low education level
poverty, unsafe environment
Domestic violence
Life stress
Number of implanted embryos in assisted reproduction
low pre-pregnancy weight
Obesity
Health problems that can be treated:hypertension, diabetes, clotting problems, anemia
Incompetent cervix
Genitourinary infection
Infection
Periodontal disease
Substance/alcohol use
Cigarette smoking
long hours of employment/standing
Late or no prenatal care
Air pollution
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Medical management-

Lung maturity

A

● Lung maturity is determined with lecithin/sphingomyelin (L/S) ratio or phosphatidylglycerol (PG) before elective induction or cesarean birth and for women in preterm labor.

● Corticosteroids, betamethasone or dexamethasone, are administered to the pregnant woman if the woman presents in preterm labor or if preterm birth is anticipated. Evidence suggests that corticosteroid administration results in reduced mortality rates as well as neonatal morbidities such as respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH). Corticosteroid administration also reduces the need for respiratory support and the length of stay in the neonatal intensive care unit (NICU)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Monitoring of

A

● Cardiorespiratory, oxygen saturation, blood gas, and end CO2 monitoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Respiratory support

A

● Respiratory support

● Nasal continuous positive airway pressure (NCPAP) or intubation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Lab tests

A

● Bilirubin level

● Blood cultures based on risk factors

● Complete blood count with manual differential

● Electrolytes

● Blood glucose

● Liver function tests

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Medications

A

● Sodium bicarbonate to treat metabolic acidosis if present

● Dopamine or dobutamine for treatment of hypotension

● Erythropoietin (EPO) administration to stimulate production of red blood cells (RBCs) if indicated

● The use of EPO reduces the need for RBC transfusions, but there is an increased risk for retinopathy of prematurity.

● Antibiotic therapy as indicated to decrease risk of infection or treatment of infection

● Opioids to treat pain associated with procedures that cause moderate to severe pain, such as with surgical procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Other medical interventions

A

● Blood transfusion if the neonate is anemic or to replace blood loss due to laboratory tests or blood loss during birth (Sherman, 2015a)

● Intravenous fluids as indicated

● Parenteral (intravenous) nutrition if indicated by the neonate’s gestational age and/or clinical condition

● Central line if long-term parenteral nutrition is required

● Umbilical artery and umbilical vein catheters

● Information about the neonate’s condition, treatment plan, and follow-up care is provided to the parents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Nursing actions-assess

A

● Review prenatal, intrapartal, and neonatal histories for any known risk factors that would potentially impact the neonate.

● Participate in resuscitation of the neonate as indicated.

● The NICU nurse, neonatologist, and/or neonatal nurse practitioner should be present at high-risk births.

● Stabilize and transfer the neonate to the NICU for ongoing specialized care.

● Perform gestational assessment to determine age of neonate if gestational age is unknown or unreliable.

● Protocols of care differ with gestational age.

● Perform a physical assessment, evaluating for problems associated with prematurity.

● Nursing care includes the immediate recognition and prioritization of problems to decrease neonatal morbidity and mortality.

● Assess for signs of respiratory distress:

● Grunting

● Flaring

● Retracting

● Cyanosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Provide respiratory support

A

● Provide respiratory support.

● Maintain a patent airway.

● Administer oxygen to maintain oxygen saturation within ordered parameters.

● Oxygen administration may be given using low- or high-flow nasal cannulas, NCPAP, or ventilator.

● Oxygen is humidified and warmed to prevent drying of mucous membranes and dropping of body temperature. A decrease in body temperature increases body metabolism, which increases the risk for hypoglycemia and respiratory distress.

● Suction airway as needed to remove secretions, as neonates have a smaller airway diameter, which increases the risk of obstruction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Maintain thermal environment

A

● Maintain neutral thermal environment by:

● Drying the infant gently immediately after birth to prevent heat loss from evaporation.

● Keeping the head covered to prevent heat loss due to radiation and convection.

● Using plastic barriers made of polyethylene to cover preterm neonates after birth to prevent heat loss and transepidermal water loss

● Using a chemical warming mattress during resuscitation and transport to the NICU

● Extremely-low-birth-weight neonates are at high risk for cold stress during the period immediately after birth. Neonates placed in plastic barriers and/or on chemical mattresses immediately after birth have higher admission temperatures upon admission to the NICU (Sharma, 2016).

● Prewarming radiant warmers, incubators, and linens

● Controlling environmental temperature with the use of servo control. A temperature-control probe should be placed on the neonate’s abdomen to assist in maintaining the neonate’s temperature within the normal range (axillary 36.3°C to 36.9°C [97.4°F to 98.4°F]) for premature neonates.

● Placing the neonate in a double-walled incubator to prevent transepidermal water loss and heat loss

● Encouraging kangaroo care (skin-to-skin care) in stable neonates

● Weaning infants gradually from incubator to an open crib

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Assessment and support for cardiovascular system

A

● Assess cardiovascular system.

● Murmurs

● Pulses

● Capillary refill

● Provide cardiovascular support.

● Monitor blood pressure, oxygen saturation, and blood gases.

● Obtain and monitor hemoglobin and hematocrit as per order.

● Administer blood transfusion as per order.

● Assess responses to interventions. These responses may be changes in breathing, oxygen saturation, vital signs, and neonatal behavior.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Maintain fluid and electrolyte balance

A

● Maintain fluid and electrolyte balance.

● Monitor input and output by:

● Weighing diapers to determine output.

● Assessing frequency, color, amount, and specific gravity of urine to determine hydration status.

● Recording fluid intake and output (I&O) from IV fluids, feedings, chest tubes, urinary catheters, stomas.

● Restrict fluid intake as per order.

● Fluid restriction is commonly ordered for neonates with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA) or other complications that can lead to pulmonary edema.

● Monitor electrolyte levels as per order.

● Hyperkalemia (elevated potassium levels), hyponatremia (low sodium level), and hypernatremia (high sodium level) may occur among low-birth-weight infants (Sherman, 2015a).

● Administer intravenous fluids as per order.

● Monitor the site of intravenous access for signs of infection, skin breakdown, and infiltration.

● Add humidity to the neonate’s environment to decrease water loss that can occur through the neonate’s immature skin, known as transepidermal water loss (TEWL).

● Humidity added to the environment prevents heat loss, improves skin integrity, decreases TEWL, and promotes electrolyte balance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Meet neonates nutrition requirements

A

● Meet the neonate’s nutrition requirements.

● Obtain and monitor blood glucose levels as per order.

● Administer parenteral nutrition (intravenous) if the neonate is unable to receive enteral feedings (via gastrointestinal tract) or is advancing slowly on feeding volumes.

● Administer trophic feedings (small volume enteral feedings) as per order. They are often given while neonates are receiving parenteral feedings to ease the transition to full enteral feedings and enhance gastrointestinal functioning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Feeding for neonates less than 2500g

A

● Low-birth-weight neonates (less than 2,500 g) and neonates less than 32 weeks’ gestation:

● May lack the ability to digest and absorb feedings.

● May have an inability to suck, swallow, and breathe.

● Will most likely require parenteral nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Enteral feedings

A

● Administer enteral feedings orally or by gastric tube (gavage feedings), depending on the infant’s gestational age and clinical condition. Most neonates who are older than 34 weeks’ gestation usually receive oral feedings soon after birth.

● Human milk reduces the risk of necrotizing enterocolitis (NEC) and is preferred for enteral feedings (Herrmann & Carroll, 2014).

● Human milk requires fortification because it does not provide the calories, protein, fat, carbohydrate, potassium, calcium, sodium, and phosphorus that the premature infant needs (Ditzenberger, 2015).

● Formulas developed specifically for preterm infants are available. These formulas are modified to promote absorption and digestion for babies with immature gastrointestinal functioning and contain the extra calories, protein, minerals, and vitamins required by preterm babies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

● Use proper technique for gavage feedings (NG tube)

A

● When feedings are initiated and before each feeding, assess for signs of feeding tolerance as follows (Ditzenberger, 2015):

● Check for the presence of bowel sounds.

● Assess the abdomen for bowel loops and discoloration.

● Measure abdominal girth.

● Check for gastric residuals by aspirating stomach contents with the syringe. Note the amount, color, and consistency of the contents.

● Assess for emesis.

● Check stools for occult blood as per order.

● Check stools for reducing substances as per order.

● Assess stools for consistency, amount, and frequency.

● Use nonnutritive sucking with a pacifier during gavage feedings. Nonnutritive sucking eases the transition from gavage feeding to bottle feeding and results in decreased length of hospital stay for preterm neonates (Foster, Psaila, & Patterson, 2016).

● Monitor weight daily. Weight gain of 10 to 20 g per kg/day indicates appropriate growth and caloric intake for a preterm neonate (Ditzenberger, 2015).

● Monitor length and head circumference weekly.

● Calculate and monitor intake of fluids, calories, and protein daily (Ditzenberger, 2015). Preterm infants require between 105 and 130 kcal/kg/day.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Transitioning from tube feedings to oral feedings

A

● Transition the neonate from tube feedings to oral feedings.

● Transitioning to oral feedings occurs when the neonate:

● Has cardiorespiratory regulation.

● Demonstrates a coordinated suck, swallow, and breathe.

● Demonstrates hunger cues such as bringing hand to the mouth, sucking on fingers.

● Maintains a quiet alert state.

● Properly position the neonate for bottle feeding by holding the swaddled baby in a semi-upright or upright position.

● Observe the neonate for respiratory status, apnea, bradycardia, oxygenation, and feeding tolerance.

● Pace feeding and allow for breathing breaks since preterm neonates may become fatigued during feedings.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Support breastfeeding

A

● Support breastfeeding.

● Evidence suggests that breast milk decreases the incidence of NEC (Herrmann & Carroll, 2014).

● When the neonate is unable to breastfeed, instruct the mother in the use of a breast pump and storage of breast milk.

● Encourage the mother to bring breast milk to the NICU so that it can be used for enteral feedings for her infant.

● Teach the mother about feeding cues, breastfeeding positions, correct latch, and evaluating the feeding.

● Encourage breastfeeding as frequently as possible to establish successful latching. Infants who successfully breastfeed in the NICU are more likely to continue breastfeeding after discharge (Briere, McGrath, Xiaomei, Brownell, & Cusson, 2016).

● Weigh the neonate before and after breastfeeding to monitor intake.

● Many mothers are hesitant to breastfeed their premature or ill neonate because they are afraid the volume will not be adequate. Weighing the neonate before and after breastfeeding can be an accurate way to demonstrate successful breastfeeding and positive mother–infant bonding (Rankin et al., 2016).

● See Appendix A for additional nursing actions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Skin care:

A

● Provide skin care as follows:

● Assess for skin breakdown and signs of infection; the thin, fragile skin of the preterm neonate is predisposed to injury

soiled areas.

● Use adhesives sparingly.

● Change diapers frequently.

● Change positions frequently.

● Apply emollients gently to avoid friction.

● Use water, air, or gel mattresses (Association of Women’s Health, Obstetric and Neonatal Nurses

Assess for signs of jaundice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Assess for signs of NEC

A

● Assess for signs of NEC, such as abnormal vital signs, abdominal distention (increase in abdominal circumference), abdominal discoloration, bowel loops, feeding intolerance, emesis, residuals, bloody stools, and behavioral changes.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Manage pain

A

● Manage pain to prevent potential long-term sensory disturbances and altered pain responses that may last into adulthood.

● Frequently assess the neonate for signs of pain, especially during painful procedures. Instruments to measure neonatal pain among preterm neonates are available and should be integrated into routine care.

● Administer sucrose and promote nonnutritive sucking during painful procedures.

● Administer opioids as per orders to treat pain associated with procedures that cause moderate to severe pain.

● Use nonpharmacological interventions such as swaddling, positioning, kangaroo care, and therapeutic touch, and decrease environmental stimulus.

● Evaluate the effectiveness of nonpharmacological and pharmacological interventions.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Small for gestational age

A

A small for gestational age (SGA) infant is one whose weight is less than the 10th percentile for his or her gestational age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Intrauterine growth restriction (IUGR)

A

Neonates whose growth is not consistent with gestational age may be affected by intrauterine growth restriction (IUGR), caused by a decrease in cell production related to chronic malnutrition. There are two types of IUGR: symmetric and asymmetric.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Symmetric IUGR,

A

, a generalized proportional reduction in the size of all structures and organs except for heart and brain, occurs early in pregnancy and affects general growth. When a complication occurs very early in pregnancy, fewer cells develop, leading to smaller organ size. Symmetric IUGR can be identified by ultrasound in the early part of the second trimester. Conditions that may result in symmetric IUGR include exposure to teratogenic substances, congenital infections, and genetic problems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Asymmetric IUGR

A

a disproportional reduction in the size of structures and organs, results from maternal or placental conditions that occur later in pregnancy and impede placental blood flow. Examples of conditions that may result in asymmetric IUGR include preeclampsia, placental infarcts, or severe maternal malnutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Factors Contributing to Intrauterine Growth Restriction

A

Maternal, fetal, placental, and environmental:

Multiple gestation, Female sex, Small placenta High altitude
Primiparity Discordant twins Abnormal cord insertion Excessive exercise
Grand multiparity Congenital anomalies Placenta previa Exposure to x-ray
Age <15 years Chromosomal syndromes Chronic abruptio placenta Exposure to toxins
Age >45 years Congenital infections Placental hemangiomas
No prenatal care Rubella
Low socioeconomic status Toxoplasmosis
Nutritional status Cytomegalovirus
Low pre-pregnancy weight Inborn errors of metabolism
Low weight gain
Substance abuse
Smoking
Vascular disease
Renal disease
Cardiac disease
Preeclampsia
Chronic hypertension
Advanced diabetes
Sickle cell anemia
Phenylketonuria
Medications
Anticonvulsants
History of stillbirth
History of preterm birth
History of IUGR/LBW baby
Maternal short stature

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Neonates with IUGR are at risk for

A

● Labor intolerance related to placental insufficiency and inadequate nutritional and oxygen reserves.

● Meconium aspiration related to asphyxia during labor.

● Hypoglycemia related to inadequate glycogen stores and reduced gluconeogenesis, and an increase in metabolic demands from heat loss, which diminishes glucose stores

● Hypocalcemia, defined as serum calcium levels less than 7.5 mg/dL, related to birth asphyxia

● Signs of hypocalcemia are often similar to those of hypoglycemia and include jitteriness, tetany, and seizures.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

● Physical characteristics of the IUGR neonate include:

A

● Large head in relationship to the body.

● Long nails.

● Large anterior fontanel.

● Decreased amounts of Wharton’s jelly present in the umbilical cord.

● Thin extremities and trunk.

● Loose skin due to a lack of subcutaneous fat.

● Dry, flaky, and/or meconium-stained skin.

● Weight, head circumference, and length are all below the 10th percentile for gestational age in symmetric IUGR

● Head circumference and length are appropriate for gestational age; however, the weight is below the 10th percentile for the baby’s gestational age in asymmetric IUGR

● RDS may occur in SGA neonates who are born prematurely or who have aspirated meconium-stained amniotic fluid.

● Hypothermia related to decreased subcutaneous fat and glucose supply, impaired lipid metabolism, and depleted brown fat stores
● Polycythemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Medical management for IUGR

A

● Identify IUGR during pregnancy and intervene based on the cause.

● Assess for congenital anomalies.

● Oxygen therapy for perinatal depression and respiratory distress

● Laboratory tests

● Blood glucose monitoring

● Hematocrit if polycythemia is suspected

● Serum calcium levels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Nursing actions

A

● Review prenatal and intrapartal records for risk factors.

● Perform a gestational age assessment to determine if neonate is SGA or preterm.

● Assess for respiratory distress.

● Assess the neonate for gross anomalies.

● Assess the skin for color and signs of meconium staining.

● Infants with meconium staining have an increased risk of respiratory distress.

● Maintain a neutral thermal environment.

● SGA infants have decreased subcutaneous fat and are more susceptible to hypothermia.

● Decrease risk of hypoglycemia.
● SGA infants are at high risk for hypoglycemia due to their decreased amount of subcutaneous fat and thus are at increased risk of cold stress.

● Assess for signs of hypoglycemia.

● Monitor blood glucose.

● Provide early and frequent feedings.

● SGA infants may need gavage feedings due to poor suck or inability to finish feedings due to lack of stamina.

● Monitor for hypocalcemia.

● Weigh daily.

● SGA infants may require higher caloric intake.

● Monitor vital signs.

● Monitor for feeding intolerance.

● SGA infants are susceptible to NEC due to placental insufficiency.

● Obtain laboratory tests as per orders.

● Teach parents the importance of keeping the baby warm and providing frequent feedings.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Large for gestational age

A

A large for gestational age (LGA) infant has a weight above the 90th percentile for his or her gestational age. Characteristically, LGA infants (Fig. 17–7) are macrosomic and have greater body length and head circumference compared to infants who are appropriate for gestational age.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

LGA risk factors

A

● Maternal diabetes

● Multiparity

● Previous macrosomic baby

● Prolonged pregnancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

LGA fetuses and neonates are at risk for

A

● Cesarean births.

● Operative vaginal delivery.

● Shoulder dystocia.

● Breech presentation.

● Birth trauma.

● Cephalopelvic disproportion.

● Hypoglycemia.

● Hyperbilirubinemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Assessment findings-LGA

A

● Birth trauma related to shoulder dystocia or breech presentation

● Fractured clavicle

● Brachial nerve damage

● Facial nerve damage

● Depressed skull fractures

● Cephalohematoma

● Intracranial hemorrhage

● Asphyxia (Hardy et al., 2016)

● Poor feeding behavior
● Hypoglycemia

● Polycythemia in neonates of diabetic mothers related to a decrease in extracellular fluid and/or fetal hypoxia

● Hyperbilirubinemia that occurs 48 to 72 hours after delivery related to polycythemia, decreased extracellular fluid, or bruising or hemorrhage from birth trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Medical management

A

● Assessments for birth trauma, hypoglycemia, and respiratory distress

● Laboratory tests:

● Blood glucose

● Hematocrit

● Bilirubin levels when indicated for jaundice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Nursing actions:LGA

A

● Review prenatal and intrapartal records for risk factors.

● Assess respiratory status.

● Assess neonates for birth traumas such as fractured clavicles, brachial nerve damage, facial nerve damage, and cephalohematoma.

● Obtain and monitor blood glucose per agency protocol.

● Observe for signs of hypoglycemia.

● LGA infants are at increased risk for hypoglycemia due to depletion of glycogen stores.

● Provide early and frequent feedings to decrease risk for hypoglycemia.

● LGA infant may feed poorly and require gavage feedings.

● Obtain and monitor hematocrit as per orders.

● High hematocrit increases the risk for jaundice.

● Assess skin color for signs of polycythemia, which appears as a red, ruddy skin color.

● Infants of diabetic mothers are at risk for polycythemia.

● Perform a gestational age assessment.

● Observe for jaundice.

● LGA infants are at higher risk for jaundice due to polycythemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Hyperbilirubinemia

A

Hyperbilirubinemia, increased levels of bilirubin in the blood,
Bilirubin exists in two major forms: unconjugated and conjugated
When serum bilirubin levels are greater than 5 mg/dL, neonates will exhibit visible signs of jaundice. The clinical significance of jaundice is based on the gestational age of the neonate, hours of life, and the total serum bilirubin level (Bradshaw, 2015). Prematurity may result in greater severity of physiological jaundice, and any jaundice among preterm neonates must be evaluated.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Unconjugated bilirubin

A

Unbound (unconjugated) bilirubin can deposit into tissue and cross the blood-brain barrier.
Bilirubin cannot be excreted until it is conjugated.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Conjugated bilirubin

A

Conjugated bilirubin is bound to albumin and once bound, is water-soluble. It is nontoxic and can be excreted by the neonate (Allen, 2015). Bilirubin cannot be excreted until it is conjugated.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Complication of Hyperbilirubinemia: Kernicterus

A

complication of hyperbilirubinemia is kernicterus, an abnormal accumulation of unconjugated bilirubin in the brain cells. Bilirubin accumulates within the brain and becomes toxic to the brain tissue, causing neurological disorders such as deafness, delayed motor skills, hypotonia, and intellectual deficits . A goal of medical and nursing actions is to prevent kernicterus through early identification and treatment of hyperbilirubinemia.

Hyperbilirubinemia is categorized into physiological jaundice and pathological jaundice.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Physiological jaundice

A

Physiological jaundice results from hyperbilirubinemia that commonly occurs after the first 24 hours of birth and during the first week of life. Common physiological characteristics of the neonate place it at risk for physiological jaundice:

● Increased RBC volume

● RBC life span of 70 to 90 days, compared to 120 days in adults

● High bilirubin production (6 to 8 mg/kg/day)

● Neonates reabsorb increased amounts of unconjugated bilirubin in the intestine due to lack of intestinal bacteria, decreased gastrointestinal motility, and increased beta-glucuronidase (a deconjugating enzyme).

● Decreased hepatic uptake of bilirubin from the plasma due to a deficiency of ligandin, the primary bilirubin binding protein in hepatocytes

● Diminished conjugation of bilirubin in the liver due to decreased glucuronyl transferase activity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Assessment findings-physiological jaundice

A

● Physiological jaundice is typically visible after 24 hours of life.

● Total serum bilirubin levels generally peak on day 3 of life in term neonates and on days 5 or 6 in preterm neonates (Bradshaw, 2015).

● Jaundice is characterized by a yellowish tint to the skin and sclera of the eyes.

● As total serum bilirubin levels rise, jaundice will progress from the newborn’s head down toward the trunk and lower extremities.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Pathological jaundice

A

Pathological jaundice results when various disorders exacerbate physiological processes that lead to hyperbilirubinemia of the newborn. Such disorders can result in pathological unconjugated or conjugated hyperbilirubinemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Assessment findings-pathological jaundice

A

● Jaundice that occurs within the first 24 hours of life

● Total serum bilirubin levels that increase by more than 5 mg/dL per day

● Jaundice lasting more than 1 week in a term newborn or more than 2 weeks in a premature neonate day

● Risk factors, medical management, and nursing actions are similar for both physiological and pathological jaundice.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Risk Factors for Hyperbilirubinemia

A

● Maternal factors

● Asian, Native American, or Greek ethnicity

● ABO incompatibility (e.g., the woman is blood type O and the neonate is blood type A or B)

● Rh incompatibility (e.g., the woman is Rh negative and the neonate is Rh positive)

● Breastfeeding (Table 17–5)

● Diabetes

● Use of oxytocin or bupivacaine during labor

● Neonatal factors

● Delayed cord clamping, which increases RBC volume

● Hypoxia, acidosis, hypothermia, or hypoglycemia

● Delayed or infrequent feedings

● Excessive weight loss after birth

● Bruising or cephalohematoma

● Prematurity

● Bacterial or viral infection (especially toxoplasmosis, syphilis, varicella-zoster, parvovirus B19, rubella, cytomegalovirus, and herpes [TORCH] infections)

● Previous sibling with hyperbilirubinemia

52
Q

Medical management for hyperbilirubinemia-

Diagnostic tests

A

● Total serum bilirubin, with fractionation of serum bilirubin into direct (conjugated bilirubin) and indirect (unconjugated bilirubin) reacting pigments.

● Antiglobulin (Coombs’) test: Used to determine hemolytic disease of the newborn related to Rh or ABO incompatibility

● Direct antiglobulin (Coombs’) test is used to detect abnormal in vivo coating of the neonate’s RBCs with antibody globulin (maternal antibodies); when present, the test is considered positive.

● Transcutaneous bilirubinometry, a noninvasive method to estimate total serum bilirubin levels among term and near-term neonates, is used to identify neonates at risk for developing hyperbilirubinemia (Hardy et al., 2016).

● Complete blood count assists in management of pathological jaundice.

53
Q

Treatment

A

● Treatment is determined by the level of bilirubin and the age of the neonate in hours (Table 17–6).

● Phototherapy is the most widely used and effective treatment for hyperbilirubinemia.

● Various types of phototherapy delivery systems are available, including blue lights, white lamps, halogen lamps, fiber-optic blankets, and blue light emitting diodes. The most effective lights are those with high-energy output in the blue-green spectrum .

● Phototherapy results in photoconverting bilirubin molecules to water-soluble isomers that can be excreted in the urine and stool without conjugation in the liver

● Total serum bilirubin levels should drop 1 to 2 mg/dL within 4 to 6 hours after the initiation of phototherapy.
● Phototherapy should be administered continuously, except during feeding times or parental visits, when eye patches are removed to allow for bonding.

54
Q

CAUSES OF PATHOLOGICAL UNCONJUGATED HYPERBILIRUBINEMIA

A

Hemolysis of RBCs
Rh/ABO incompatibilities
Bacterial and viral infections
Inherited disorders of RBC/bilirubin metabolism
Glucose-6-phospate dehydrogenase deficiency

Sequestered Blood
Cephalohematoma
Bruising
Hemangiomas
Cerebral, pulmonary, retroperitoneal bleeding
Decreased hepatic uptake of bilirubin
Decreased hepatic function/perfusion
• Hypoxia
  • Asphyxia
  • Sepsis

Increased enterohepatic circulation
• Delayed feedings

  • Breastfeeding jaundice
  • Breast milk jaundice
  • Intestinal obstructions

Polycythemia
Swallowed blood
Hypothyroidism
Hypopituitarism

55
Q

CAUSES OF CONJUGATED HYPERBILIRUBINEMIA (ALWAYS PATHOLOGIC)

A
Hepatitis
Neonatal idiopathic hepatitis
Infectious hepatitis
Toxic hepatitis
Intestinal obstruction
Ischemic necrosis
Parenteral alimentation
Metabolic disorders
Hematological disorders
Ductal disturbances in bilirubin excretion:
• Extrahepatic biliary atresia
  • Intrahepatic biliary atresia
  • Bile plug syndrome
  • Tumors of the liver and biliary tract
56
Q

CRITICAL COMPONENT

Fiber-Optic Blanket (Bili Blanket)

A

Bili Blanket-
a portable phototherapy device-can be used in home or in hospital for hyperbilirubinemia.
The blanket, a fiber-optic panel connected to a power source, is wrapped around the bare torso of the infant..
The infant and the bili blanket can be covered with clothing and/or a regular blanket. The bili blanket remains on the infant 24 hours a day. Parents can hold and feed the infant with the blanket in place. Blood tests to assess bilirubin levels are used to determine effectiveness of the therapy.

57
Q

Treatments-

Exchange transfusions

A

Exchange transfusion is used in cases where phototherapy is not effective or severe hemolytic disease is present.

● In this procedure, approximately 85% of the neonate’s RBCs are replaced with donor cells.

● This procedure reduces bilirubin, removes RBCs coated with maternal antibody, corrects anemia, and removes other toxins associated with hemolysis.

● Efforts to prevent Rh hemolytic disease with Rh immunoglobulin (RhoGam) administered to Rh-negative women, along with the use of phototherapy, has diminished the need for exchange transfusion.

● Infants discharged before 72 hours of life should be seen for follow-up by a health care provider within 1 to 2 days to assess the neonate’s health status and to assess for jaundice.
● Early identification and treatment decrease the risk of bilirubin encephalopathy

58
Q

Hyperbilirubinemia Associated With Breastfeeding: A Comparison of Breastfeeding Versus Breast Milk Jaundice(table 17-5)

Breastfeeding Jaundice

A

Early onset of jaundice (within the first few days of life).
Associated with ineffective breastfeeding.
Dehydration can occur.
Delayed passage of meconium stool promotes reabsorption of bilirubin in the gut.
Treatment: Encourage early effective breastfeeding without supplementation of glucose water or other fluids.

59
Q

Breastmilk jaundice

A

Late onset (after 3–5 days).
Gradual increase in bilirubin that peaks at 2 weeks of age.
Associated with breast milk composition in some women that increases the enterohepatic circulation of bilirubin.
Treatment: Continued breastfeeding in most infants. In some cases where bilirubin levels are excessively high, breastfeeding may be interrupted and formula feedings are given for several days. This typically results in a decline of the bilirubin level. Breastfeeding is resumed when bilirubin levels decline.

60
Q

Management of Hyperbilirubinemia in the Healthy Term and Near-Term Neonate(table 17-6)

A

AGE (HR), CONSIDER PHOTOTHERAPY, PHOTOTHERAPY
~≤24

~25–48-Consider phototherapy ≥12,
Phototherapy-≥15

49–72-Consider phototherapy-≥15, Phototherapy-≥18

> 72-Consider phototherapy-≥17-Phototherapy-≥20

61
Q

Nursing Actions for Hyperbilirubinemia

A

● Review maternal and neonatal record for risk factors.

● Assess degree of jaundice every shift with the use of a transcutaneous meter.

● When meter is not available, in a well-lit area, use your fingers to blanch the neonate’s skin on the face, upper trunk, abdomen, thigh, and lower leg and feet. The skin will appear yellow after the pressure is released and before skin returns to normal color.

● Document the assessment findings.

● How rapidly the degree of jaundice progresses guides the method of treatment.

● Notify the physician if jaundice is present.
● Obtain serum bilirubin levels as per orders.

● The rate of rise of the bilirubin level is critical in determining the treatment needed.

62
Q

Nursing actions- treatments

A

● Ensure adequate hydration by feeding the neonate every 2 to 3 hours to promote excretion of bilirubin in the urine and stool and to compensate for insensible water loss due to phototherapy (Hardy et al., 2016).

● Implement phototherapy as ordered and provide related nursing care.

● Proper nursing care enhances the effectiveness of phototherapy and minimizes complications.

63
Q

Assess for side effects of phototherapy

A

● Assess for side effects of phototherapy:

● Eye damage

● Loose stools

● Dehydration

● Hyperthermia

● Lethargy

● Skin rashes

● Abdominal distention

● Hypocalcemia

● Lactose intolerance

● Thrombocytopenia

● Bronze baby syndrome: Dark gray-brown pigmentation of skin that disappears after phototherapy is discontinued.

64
Q

Nursing actions-discharge

A

● Provide verbal and written discharge instructions about how to identify signs of jaundice in an infant and when to notify the physician.

● For those infants discharged with mild jaundice, teaching should include measures to assess hydration, excretion of bilirubin, and home management of phototherapy lights if applicable.

65
Q

CRITICAL COMPONENT

Care of the Neonate Receiving Phototherapy

A
  • Fluorescent lights
  • Fluorescent “bili lights” should be positioned 18 to 20 inches from the infant.
  • Fluorescent lights should be positioned 2 inches from the top of an incubator.
  • A photometer should be used to measure irradiance of lamps to facilitate optimal treatment.
  • Banks of lights should be covered by Plexiglas.
  • The neonate should have only a diaper in place for maximal exposure to light.
  • Place eye patches on the neonate to protect eyes from the effects of the light.
  • During feedings, remove eye patches and have parent or nurse hold the neonate.
  • Change the neonate’s position frequently to facilitate increased exposure to the light.
  • Vital signs, including temperature monitoring, should be done per agency protocol.
  • Monitor I&O. Phototherapy results in increased insensible fluid loss.
  • Feedings every 2 to 3 hours are important to provide adequate fluids to compensate for insensible fluid loss and promote excretion of bilirubin.
  • Monitor newborn for side effects of phototherapy.
66
Q

CENTRAL NERVOUS SYSTEM INJURIES

A

Various types of central nervous system (CNS) injuries can occur among term and premature neonates. Injury can be the result of intracranial hemorrhage (Table 17–7),
hypoxia
ischemia during the prenatal and intrapartal periods and postbirth, systemic chronic fetal compromise such as IUGR, or
hypotension that leads to a decreased cerebral perfusion resulting in preventricular leukomalacia.

Outcomes depend on location and extent of injury
Can have normal outcome or serious long-term problems such as seizures, neurological deficits, developmental disability, motor deficits, visual impairments, or death

67
Q

Risk factors for CNS injuries

A

● Prematurity

● Birth trauma

● Breech delivery or other malpresentations

● Precipitous labor

● Difficult labor, traumatic delivery, and use of forceps

● Hypoxia, asphyxia, hypotension, ischemia, respiratory distress. Hypoxic events may be related to:

● Maternal causes such as cardiac arrest and hypovolemic shock.

● Uteroplacental causes such as placental abruption, cord prolapse, and uterine hyperstimulation.

● Fetal causes such as cardiac arrhythmias

68
Q

Medical management

A

● Decrease risk for hypoxia, ischemia, and asphyxia during the perinatal and intrapartal periods.

● Identification and treatment of a compromised fetus may prevent asphyxiation and multiorgan damage (Verklan, 2015).

● Neurological and behavioral evaluation
● Neurology consultant as indicated

● Medications to treat seizure activity

69
Q

Lab tests

A

● Laboratory tests

● Serum glucose level

● Electrolyte levels

● Arterial blood gas analysis

● Blood, urine, CSF cultures

● Complete blood count with differential

70
Q

Other tests

A

● Computed tomography (CT) scan, ultrasonography, magnetic resonance image (MRI), and skull radiographs as indicated

● Lumbar puncture for CSF analysis if clinically indicated

● Electroencephalography to confirm occurrence of seizures and to identify presence and severity of brain damage if clinically indicated

71
Q

Hypoxic-ischemic encephalopathy medical management

A

● Infants with hypoxic-ischemic encephalopathy may require the following medical management and treatment (Verklan, 2015):

● Resuscitation at the time of delivery

● Oxygen and ventilator support

● Monitoring of fluids, electrolytes, and acid-base balance

● Monitoring of blood volume and blood pressure.
● Maintaining perfusion and preventing/treating hypotension

● Evaluating and supporting the renal, hepatic, gastrointestinal, pulmonary, and cardiovascular systems

● Total body cooling or selective head cooling for infants with moderate to severe hypoxic-ischemic encephalopathy to improve survival and neurodevelopment

72
Q

Types of Central Nervous System Injuries: Hemorrhages

SUBDURAL HEMORRHAGE

A

Definition:Tear of the dura overlying the cerebellum or cerebral hemispheres.

Pathophysiology
Excessive molding, stretching, or tearing of the falx and tentorium.

Stretching or tearing of the vein of Galen or cerebellar bridging veins.

Manifestations:	Symptoms may be delayed for first 24 hours, then:
	Seizures
Decreased level of consciousness
Asymmetrical motor function
Full fontanel
Irritability	 	 
 	Lethargy	 	 
 	Respiratory abnormalities	 	 
 	Facial paralysis

Prognosis
Hydrocephalus

Mortality rate 45%

Hypoxic–ischemic injury

73
Q

SUBARACHNOID HEMORRHAGE

A

Definition: Intracranial hemorrhage into the cerebrospinal fluid–filled space between the pial and arachnoid membranes on the surface of the brain.

Most common neonatal intracranial hemorrhage.

Pathophysiology:
May occur because of trauma in a term neonate or hypoxia in a preterm neonate.

Venous bleeding in the subarachnoid space related to ruptured small vessels in the leptomeningeal plexus or bridging veins in the subarachnoid space.

Manifestations: Commonly there are no symptoms. Seizures may occur, starting on day 2 of life. Apnea may occur in preterm neonates.

Prognosis: 90% of babies with seizures will have normal follow-up.

Abnormal outcome is rare.

74
Q

INTRACEREBELLAR HEMORRHAGE

A

Definition: Hemorrhage in the cerebellum from primary bleeding or from extension of intraventricular or subarachnoid hemorrhage into the cerebellum.

Occurs more commonly in preterm, LBW neonates.

Pathophysiology:
Breech presentation, difficult forceps delivery, external pressure over the occiput

History of a hypoxic–ischemic insult

Vitamin K deficiency

Vascular factors

Manifestations:
Manifestations occur within the first 2 days to 3 weeks of life. Apnea, Bradycardia,
Decreasing hematocrit, Bloody cerebrospinal fluid

Prognosis: Poorer outcome in preterm neonates than in term newborns.

Neurological deficits probable.

75
Q

Nursing actions

A

● Review maternal prenatal and intrapartal histories for risk factors.

● Perform physical assessment of the neonate, including evaluation of tone, reflexes, and behavior.

● Maintain respiratory support as needed.

● Obtain laboratory tests as per order.

● Ensure that ordered diagnostic tests are completed.

● Assist with diagnostic procedures such as lumbar puncture.

● Administer medications as per order.

● Manage neonates receiving cooling therapy.

● Provide the family with support and information about their infant’s status, treatment, and follow-up.

76
Q

INFANTS OF DIABETIC MOTHERS

A

Diabetes is the most common chronic medical problem affecting pregnant women (Hay, 2012). Maternal diabetes during pregnancy is associated with poor outcomes for the fetus and neonate .

77
Q

Complications of high maternal levels of glucose during pregnancy

A

● Congenital anomalies:

● Cardiac anomalies, such as transposition of the great vessels, ventricular septal defect, and left to right ventricular wall hypertrophy

● Skeletal defects, such as sacral agenesis and neural tube defects

● Small left colon syndrome and renal anomalies (Hay, 2012)

● IUGR, perinatal asphyxia, and SGA due to placental insufficiency (Armentrout, 2015)

● Neurological damage and seizures related to inadequate glucose supply to the brain due to neonatal hyperinsulinism

● Risk of childhood obesity and type 2 diabetes (

78
Q

More CNS system injuries: HYPOXIC–ISCHEMIC ENCEPHALOPATHY

A

Abnormal neonatal neurological behavior resulting from a hypoxic–ischemic event.Brain edema and massive cellular necrosis.
Intraventricular, subdural, or intracerebral hemorrhage.

Risk Factors Hypoxia, anoxia, decreased blood supply to the brain (ischemia).
Acute birth asphyxia (e.g., cord compression).
Chronic subacute asphyxia (prenatal or intrapartum).Systemic hypotension. Multiorgan system failure may occur.

Clinical Manifestations	Clinical manifestations depend on extent of encephalopathy.
Stage I:
Mild encephalopathy
Hyperalert state
Hyperresponsiveness
Normal muscle tone and reflexes	 
 	Increased tendon reflexes	 
 	Myoclonus present	 
 	Tachycardia	 
 	Dilated pupils	 
 	EEG normal	 
 	Usually no seizure activity	 
 	Stage II:	 
 	Moderate encephalopathy	 
 	Lethargy and hypotonia	 
 	Increased tendon reflexes	 
 	Myoclonus	 
 	Weak suck	 
 	Strong grasp	 
 	Incomplete Moro reflex	 
 	Seizures	 
 	Pupils constrict and reactive	 
 	Abnormal EEG findings	 

Stage III:
Severe encephalopathy
Level of consciousness deteriorates to comatose
Apnea, bradycardia
Mechanical ventilation needed.
Seizures occur within 12 hours of life.
Severe hypotonia, absent Moro, grasp, and suck reflexes.
Pupils unequal; poor light reflex and variable reactivity.
Deterioration may occur within 24–72 hours.
Death may follow.

Prognosis:
Outcome depends on severity of encephalopathy. 20%–50% of asphyxiated babies with hypoxic–ischemic encephalopathy (HIE) will die. Early seizure activity associated with poorer outcome. Less severe HIE associated with hyperactivity and attention deficit problems. Normal outcome may occur.

79
Q

PERIVENTRICULAR LEUKOMALACIA

A

Necrosis of periventricular white matter resulting from ischemia.
Ischemic lesion of arterial origin.
Multicystic encephalomalacia with/without hemorrhage into ischemic area.

Risk factors:
Systemic hypotension leading to decreased cerebral blood flow.
Apnea and bradycardia, secondary to poor cerebral perfusion.
Chorioamnionitis

Clinical manifestations:
Acute phase:
Lethargy, CNS depression, and hypotension.
After 6–10 weeks:
Frequent tremors, and startle reflex.
Abnormal Moro reflex.
Hypertonia, irritability, extension of legs, increased flexion of arms.

Prognosis:
Outcome depends on location and extent of injury.
Motor deficits
Spastic diplegia
Visual impairments
Lower limb weakness
Intellectual deficits more common when there is upper arm involvement.

80
Q

Assessment findings- infants with diabetic mothers

Macrosomia-

A

● Macrosomia

● Increased birth weight due to fetal exposure to elevated maternal glucose levels. In response to high glucose levels, the fetal pancreas produces insulin. Hyperinsulinemia results in increased fat production and growth
● Fractured clavicle and/or brachial nerve damage

● Macrosomic neonates are at risk for traumatic deliveries, including shoulder dystocia.

81
Q

Hypoglycemia

A

● Hypoglycemia

● Risk of hypoglycemia due to increased levels of fetal and neonatal insulin and decreased circulating glucose after delivery

82
Q

Potential findings infant with diabetic mothers

A

● Hypocalcemia and hypomagnesemia

● Polycythemia

● Caused by insulin-induced increases in metabolism that leads to hypoxia
● Hyperbilirubinemia

● Polycythemia increases risk of hyperbilirubinemia.

● Low muscle tone

● Poor feeding abilities

● Respiratory distress

● Risk for RDS due to delay in surfactant production related to the high maternal glucose levels and fetal hyperstimulation (

83
Q

Assess for

A

● Assess for complications associated with maternal diabetes.
● Assess neonate for signs of respiratory distress, birth trauma, congenital anomalies, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia.

84
Q

Labs and tests

A

● Perform laboratory tests such as hematocrit and calcium and magnesium levels

● Perform X-ray exams if clinically indicated for birth trauma related to shoulder dystocia

● Consult the cardiologist if cardiac anomalies are suspected.

● Monitor blood glucose. Abnormal results are confirmed by laboratory analysis of plasma glucose (Armentrout, 2015). If the neonate is hypoglycemic, blood glucose levels should be monitored 30 minutes after feeding to evaluate response to treatment.

● Early (by 1 to 2 hours of age) and frequent oral feedings of breast milk or formula unless the neonate feeds poorly or is too sick to be fed orally. If oral feedings are contraindicated and/or the neonate is hypoglycemic, there are two methods of treatment:

● 40% dextrose gel is administered by syringe in the neonate’s buccal cavity (Bennett, Headtke, & Rowe-Telow, 2015).

● 10% dextrose and water is administered intravenously.

85
Q

Nursing actions

A

● Monitor blood glucose per agency protocol.

● May require intravenous fluids along with feedings to maintain adequate blood glucose levels.

● Provide early and frequent feedings to treat and prevent hypoglycemia.

● May be passive, lethargic, and difficult to arouse.

● Oral feeding skills must be assessed and supported.

● Gavage feedings may be indicated.

● Obtain laboratory tests as per orders.

● Maintain a neutral thermal environment to reduce energy needs.

86
Q

Neonatal infection

A

Infections among neonates are a leading cause of morbidity and mortality. The immune system of a neonate is immature, placing the infant at risk for infection during the first several months of life.

87
Q

Types of infections

A

Infections are caused by bacteria, viruses, arboviruses (Zika), fungus, yeast, spirochetes (syphilis), and protozoa
Infections may affect specific organ systems such as respiratory, urinary tract, brain, gastrointestinal tract, and skin or local sites such as the umbilical stump and eyes.
-some infections infants are asymptomatic at birth and develop symptoms within few days of life,
or their initial assessment reveals findings related to an infection such as microcephaly (cytomegalovirus [CMV] and Zika) or prominent rashes (chickenpox and rubella).

88
Q

Neonatal sepsis

A

Neonatal sepsis can be classified into three categories based on age of onset: early onset, late onset, and very late onset.

89
Q

Neonatal sepsis early onset

A

Early-onset sepsis occurs within the first 7 days of life. It is a serious, overwhelming infection that is typically acquired through vertical transmission from the mother

90
Q

Neonatal sepsis late onset

A

Late-onset sepsis occurs after 7 days of life and is associated with a lower mortality rate than early-onset sepsis.

91
Q

Neonatal sepsis very late onset

A

Very-late-onset sepsis affects premature and very-low-birth-weight babies after 3 months of age. This type of sepsis is related to long-term use of equipment such as indwelling catheters and endotracheal tubes

92
Q

Transmission

A

Neonates are exposed to infection via vertical or horizontal transmission

93
Q

Vertical transmission

A

Vertical transmission, the passing of infection from the mother to the baby, can occur in several ways:

● Transplacental transfer: Infection is transmitted to the fetus through the placenta (e.g., syphilis, CMV, and Zika).

● Ascending infection: Infection ascends into the uterus related to prolonged rupture of membranes.
● Intrapartal exposure: The neonate is exposed to infection during the birth process (e.g., herpes virus).

94
Q

Horizontal transmission

A

Horizontal transmission (nosocomial infection) is transmitted from hospital equipment or staff to the neonate

95
Q

Risk factors for neonatal infection includes maternal , infant and environmental factors

A

Poor prenatal nutrition Prematurity Length of stay in hospital
Low socioeconomic status Birth weight <2,500 g Invasive procedures
Substance abuse Difficult delivery Use of humidification in incubator or ventilatory care
History of sexually transmitted infection Birth asphyxia Routine use of broad-spectrum antibiotics
Recurrent abortion Meconium staining
Lack of prenatal care Need for resuscitation
Prolonged rupture of membranes (> 12–18 hours) Congenital anomalies
Vaginal GBS colonization Black neonates
Chorioamnionitis Male neonates
Maternal temperature during labor and delivery Multiple gestation
Premature labor
Difficult or prolonged labor
Maternal urinary tract infection
Invasive procedures during labor and delivery
Maternal and/or fetal tachycardia
Fetal scalp electrode use

96
Q

Causes of neonatal infection,

A
Bacterial:
Group B Streptococcus
Escherichia coli
Coagulase-negative
Staphylococcus
Staphylococcus aureus
Viridans streptococci
Enterococcus species
Group D Streptococcus
Pseudomonas species	 	 	 
Klebsiella	 	 	 
Listeria monocytogenes	 	 	 
Hemophilus influenzae	 	 	 
Neisseria gonorrhoeae	 	 	 
Chlamydia trachomatis	 	 	 
Chlamydia	 	 	 
Mycobacterium tuberculosis
Viral:
Rubella
CMV
Respiratory syncytial virus
Herpes simplex
Hepatitis B
HIV
Varicella-zoster(chickenpox)
Zika(arbovirus)

Fungal:
Candida albicans
Candidiasis

Other:
Syphilis
Treponema pallidum (spirochete)
Toxoplasmosis
Protozoan parasite
97
Q

Group B Streptococcus

A

Group B Streptococcus (GBS) is the primary cause of neonatal meningitis and sepsis in the United States.
Approximately 15% to 40% of all pregnant women are asymptomatic carriers of GBS, which is found in the urogenital and lower gastrointestinal tract (.
Evidence supports the use of antibiotics during labor among women who have positive cultures for GBS during pregnancy in reducing vertical transmission of GBS and early-onset GBS sepsis

98
Q

recommendations established by the CDC (2014) to prevent perinatal GBS infection:

A

All pregnant women should be routinely screened for vaginal and rectal GBS colonization at 35 to 37 weeks’ gestation. Women who are positive for GBS should be given prophylactic antibiotics at the time of labor or rupture of membranes.

● Women who were GBS positive during pregnancy or who have delivered a previous baby with GBS infection, or women with membrane rupture before 37 weeks’ gestation should be given penicillin during the intrapartum period without obtaining a GBS culture.

● If GBS status is unknown at the time of rupture of membranes or labor onset, prophylactic antibiotics should be administered if (1) membranes have been ruptured for 18 hours or more, (2) gestational age is less than 37 weeks, or (3) maternal temperature is 100.4°F (38°C) or higher.

● Women with positive GBS cultures who have a planned cesarean section before rupture of membranes or the onset of labor should not receive routine prophylaxis for perinatal GBS prevention.

● For intrapartum chemoprophylaxis, penicillin G is recommended at an initial dose of 5 million units intravenously (IV), followed by 2.5 million units every 4 hours until delivery. Ampicillin can be used as an alternative and is given at an initial dose of 2 g IV followed by 1 g IV every 4 hours until delivery. Women who are allergic to penicillin but are not at high risk for anaphylaxis are given cefazolin intravenously. Erythromycin or clindamycin may also be used intravenously if the GBS isolate is not resistant to these medications.

● Neonates of women who received intrapartum chemoprophylaxis do not require routine antibiotic administration unless they exhibit signs of sepsis.

● Asymptomatic infants of mothers who received prophylactic antibiotics and who are less than 35 weeks’ gestation at the time of delivery should be evaluated with a complete blood count with differential and blood cultures. These neonates should be observed in the hospital for at least 48 hours.

● Infants at any gestational age who exhibit signs of infection should have a complete blood count (CBC) with a differential, blood cultures, and a chest x-ray if respiratory symptoms are present (Leonard & Dobbs, 2015). Antibiotics (ampicillin and gentamicin) should be started immediately after blood cultures are obtained.

● Neonates who are term, who appear to be healthy, and whose mothers received 4 or more hours of antibiotic prophylaxis can be discharged after 24 hours if they meet all other discharge criteria.

99
Q

Assessment Findings for Neonatal Infections

A

● Signs of infection in a newborn are often nonspecific and subtle (Table 17–11).

● Laboratory findings suggestive of infection include:

● Leukocytosis: An elevated white blood cell (WBC) count (greater than 25,000/mm3)

● Leukopenia: A low WBC count (lower than 1,750/mm3)

● Neutrophilia: Increased neutrophil count

● Neutropenia: Decreased neutrophil count (less than 1,500/mm3) is strongly predictive of infection.

● An immature to total neutrophil ratio greater than 0.20 is suggestive of infection.

● Thrombocytopenia: Platelet count below 100,000/mm3 can be related to viral infection or bacterial sepsis.

100
Q

Laboratory tests for infant exhibiting signs of sepsis or is at risk

A

● Laboratory tests to perform if the neonate exhibits signs of infection or is at risk for infection include:

● CBC, including a differential to evaluate WBC counts.

● Microbial cultures of the blood, urine, and CSF.

● Neonatal sepsis can be diagnosed definitively only with a positive blood culture (Leonard & Dobbs, 2015). Urine and CSF cultures may also be obtained when sepsis is suspected. Other cultures are obtained as clinically indicated (e.g., skin).

● C-reactive protein levels may be measured every 12 hours to detect inflammation associated with infection (Wilson & Tyner, 2015).

● Polymerase chain reaction testing for bacterial or viral DNA allows for identification of a specific bacterial or viral gene segment

101
Q

Signs of neonatal infection

A
RESPIRATORY
Apnea
Grunting
Retractions
Tachypnea
Cyanosis

THERMOREGULATION
Hypothermia
Fever
Temperature instability

CARDIOVASCULAR
Bradycardia
Tachycardia
Arrhythmias
Hypotension
Hypertension
Decreased perfusion
NEUROLOGICAL
Tremors
Lethargy
Irritability
High-pitched crying
Hypotonia
Hypertonia
Seizures
Bulging fontanelles
GASTROINTESTINAL
Poor feeding
Vomiting
Diarrhea
Abdominal distension
Enlarged liver/spleen
SKIN
Rash 
Pustules
Vesicles
Pallor
Jaundice
Petechiae
Vasomotor instability

METABOLIC
Glucose
instability
Metabolic acidosis

102
Q

Therapy/treatments for infection/sepsis

A

● Antibiotic therapy, if indicated for suspected sepsis after cultures are obtained

● Antibiotics, such as ampicillin and aminoglycosides, that provide broad-spectrum coverage are often started initially (Wilson & Tyner, 2015).

● If culture results are negative, antibiotics will be stopped after 48 to 72 hours.

● If sepsis is confirmed, antibiotics continue for 10 to 14 days, and 21 days for meningitis (Wilson & Tyner, 2015).

● If it is determined the infection is not bacterial in nature, appropriate antiviral or antifungal medications are ordered (Leonard & Dobbs, 2015).

● The dosage and frequency of medication administration are dependent on the neonate’s weight, gestational age, postnatal age, and liver and kidney function (Leonard & Dobbs, 2015).

● Intravenous fluids, parenteral nutrition and/or feedings

● Monitor glucose and electrolytes

● Ventilation as indicated

103
Q

Nursing actions:

Assess and monitor

A

● Assess maternal and neonatal histories for factors that may place a neonate at risk for infection, such as maternal GBS status.

● Monitor vital signs, I&O, and weight.

● Assess neonate for signs of infection (see Table 17–11).

● Notify the physician if the neonate demonstrates signs of infection. Early recognition and treatment of neonatal infection is important in preventing morbidity and mortality.
● Monitor glucose and electrolytes.

104
Q

More nursing actions

A

● Provide respiratory support as needed.
● Obtain laboratory tests as per order.

● Assist with diagnostic tests such as lumbar puncture for CSF.

● CSF is obtained and sent to lab for a Gram stain and culture.

● Holding the infant still in a flexed position is imperative for a successful lumbar puncture.

● Administer antibiotics as per orders.

● Administer feedings, intravenous fluid, and parenteral nutrition as per orders.

● Utilize standard precautions.

● Wash hands before handling equipment and caring for the neonate.

● Implement contact, droplet, or enteric precautions depending on diagnosis.

● Provide parents with information about the neonate’s status, infection prevention strategies such as hand washing before contact with the baby, and diagnostic tests and treatments as appropriate.

105
Q

Substance abuse exposure

A

Effects of perinatal maternal substance use on the neonate are specific to the substance and have both short-term and long-term effects on the developing fetus and neonate

106
Q

Neonatal abstinence syndrome

A

Neonatal abstinence syndrome (NAS) is a group of signs and neurological behaviors exhibited by neonates resulting from the abrupt discontinuation of intrauterine exposure to various substances, including heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines.
NAS can occur in 55% to 94% of newborns whose mothers were addicted to or treated with opioids while pregnant

107
Q

Factors affecting extent to which a newborn experiences withdrawal.

A

The extent to which a newborn exhibits drug withdrawal is dependent on timing of the last exposure, type of substance, and the half-life of the substance

Neonates exposed to alcohol in utero may demonstrate withdrawal symptoms within 3 to 12 hours after birth . Neonates exposed to narcotics in utero exhibit withdrawal within 48 to 72 hours after birth. Neonates exposed to barbiturates in utero exhibit withdrawal between days 1 and 14.

108
Q

Signs of Neonatal Withdrawal

A
  • Apnea
  • Behavior irregularities
  • Diarrhea
  • Dysmature swallowing
  • Excessive crying
  • Excessive/frantic sucking
  • Excoriated skin
  • Fever
  • High-pitched cry
  • Hyperreflexia
  • Hypertonia
  • Irritability/restlessness
  • Lacrimation
  • Nasal congestion
  • Poor feeding
  • Seizures
  • Skin mottling
  • Sleep problems
  • Sneezing
  • Sweating
  • Tachypnea
  • Tremors
  • Vomiting
  • Wakefulness
  • Weight loss or failure to gain weight
  • Yawning
109
Q

Substances commonly used during pregnancy -Signs of withdrawal, short and long term effects.
Tobacco

A

Tobacco

effects/signs of withdrawal-None known

Short and long term effects-Low birth weight
 	 	IUGR
 	 	Smaller head circumference
 	 	Increased stillbirth
 	 	Cleft palate/lip
 	 	Childhood cancer
 	 	Lower IQ
 	 	Learning difficulties
 	 	Attention deficit disorder
 	 	Increased risk for sudden infant death syndrome (SIDS)
 	 	Increased risk for asthma/respiratory infections
 	 	Inner ear infections
110
Q

Alcohol

A
Effects/signs of withdrawal-Onset of withdrawal 12 hours after birth
Hypertonia
Tremors
Weak suck
Poor feeding
Crying
Increased wakefulness	
Increased mouthing behavior
Short and long term effects:
Facial anomalies:
 	Flat upper lip
 Flat philtrum
 Short eye openings
 Low birth weight
Failure to thrive
 Microcephaly
 	Mental retardation
 	 Poor fine motor skills
 	 	Aggressiveness
 Attention deficit disorder
 Poor short-term memory
 Problem-solving difficulties
 Neurosensory hearing losses
 Gait problems
 Hand-eye coordination problems
 Increased risk of infection
Lack of understanding of consequences
 Impulsive behavior
 Poor judgment
 Short attention span
111
Q

Cannabis

A
Effects/Signs of withdrawal-
Tremors
Altered sleep patterns
High pitched cry
Exaggerated startle reflex
Short/long term effects-
Social interaction problems
Low birth weight
Preterm birth
IUGR
Attention deficit disorder
 	 	Impulsiveness
 Poor self-directed responses
 Lower scores on verbal and memory assessments
 Increased risk for SIDS with paternal use
 Congenital anomalies
112
Q

Cocaine

A
Effects/signs of withdrawal
Tremors 
Hyperreflexia
hypotonia 
abnormal state patterns prolonged periods of being awake crying 
extreme sensitivity to stimuli easily distressed 
depressed interactive behaviors 
for response to comforting 
short attention to stimuli 
pours suck leading to feeding problems 

Short/long term effects
prematurity
IUGR
decreased head circumference
low birth weight
congenital anomalies
fetal distress during labor may lead to meconium aspiration
cerebrovascular accident, intraventricular hemorrhage
Increased risk for SIDS
attention deficit and behavioral problems
cognitive delays

113
Q

Methamphetamines

A
Effects/signs of withdrawal
Abnormal sleep patterns 
tremors 
poor feeding 
state disorganization 
agitation lethargy 
weight game problems 
sweating 
vomiting
with methamphetamine and cocaine use :
frantic first sucking 
high pitched cry 
loose stools 
yawning 
fever 
hyperreflexia  
excoriation 
Short/long term effects
IUGR
reduce brain growth 
developmental effects 
congenital anomalies 
increased risk for SIDS
114
Q
Narcotics/opioids
Heroin
Methadone
Morphine 
Oxycontin
A
effects/signs of withdrawal:
Hypertonia
Tremors
Hyperreflexia
Seizures
Irritability/restlessness
High pitched cry
Excessive crying
sleep problems 
wakefullness
yawning
Nasal congestion	 
Sneezing	 
 Lacrimation	 
Sweating	 
Fever	 
Skin mottling	 
Diarrhea	 
Vomiting	 
Poor feeding	 
Dysmature swallowing	 
Excessive/frantic sucking	 
Tachypnea	 
Apnea	 
Excoriated skin	 
Behavior irregularities	 
Weight loss or failure to gain weight
short/longterm effects
Prematurity
Hypoxia/low apgar scores
IUGR
Low birth weight
Microcephaly
Increased risk for meconium stained fluid/meconium aspiration
Congenital infections
Increased risk for SIDS
Increased chromosomal abnormalities(heroin exposure)
115
Q

Prenatal Alcohol Exposure

A

Alcohol use during pregnancy can have no effect or it can cause a wide range of problems, including major long-term disabilities (Sherman, 2015b), fetal alcohol syndrome, alcohol-related birth defects, and alcohol-related neurodevelopment disorders.

116
Q

Fetal alcohol syndrome (FAS)

A

Fetal alcohol syndrome (FAS) includes a wide spectrum of physical, cognitive, and behavioral abnormalities associated with maternal alcohol use during pregnancy (Hudak, 2015). Signs of FAS include:

● Distinctive facial features: Small eyes, thin upper lip, and short nose.

● Heart defects.

● Joint, limb, and finger deformities.

● Delayed physical growth, both intrauterine and postbirth.

● Vision problems.

● Hearing problems.

● Mental retardation.

● Behavior disturbances, such as short attention span, hyperactivity, and poor impulse control (Hudak, 2015).

117
Q

Alcohol related birth defects

A

Alcohol-related birth defects are congenital anomalies associated with alcohol use during pregnancy that may affect the heart, skeleton, kidneys, eyes, and ears.

Alcohol-related neurodevelopmental disorder involves abnormalities of the central nervous system and include:

● Neurological problems (e.g., poor hand-eye coordination and fine motor skills, and neurosensory hearing loss).

● Decreased cranial size, brain abnormalities.

● Cognitive and behavioral problems

118
Q

Medical management

Assess and identify neonates at risk

A

● Identify neonates at risk.

● Physical assessment of the neonate, including observation for physical and behavioral effects of prenatal substance use.

● Use of an assessment tool to quantify the severity of signs and symptoms

● Use of the tool should be initiated within 2 hours of birth, and neonates should be assessed for signs of withdrawal every 3 to 4 hours (Sherman, 2015b).

● Use the tool to guide decisions about when a neonate should be evaluated for treatment with medication

119
Q

Tests and screening

A

● Toxicology screening of the neonate’s urine and/or meconium.

● Diagnostic tests such as cranial ultrasound and EEG, if indicated by clinical manifestations of withdrawal symptoms

● Problems such as infection and hypoglycemia may manifest symptoms similar to those of neonatal withdrawal and should be ruled out by the appropriate diagnostic tests (AAP, 2012).

120
Q

Treatments

A

● Pharmacological therapy is considered if seizures, excessive weight loss, dehydration, poor feeding, diarrhea, vomiting, fever, and inability to sleep occur (AAP, 2013).

● Medications to treat withdrawal in neonates include:

● Methadone, morphine, clonidine, and phenobarbital for opioid withdrawal.

● Benzodiazepines to treat withdrawal from alcohol.

● Frequent, small feedings with a high calorie formula (22 to 24 calories/oz.)

● Monitor feedings, output, and weight daily.

121
Q

Breastfeeding

A

● Patient education regarding substance use and breastfeeding

● Breastfeeding is contraindicated if a woman is actively using cocaine, methamphetamines, alcohol, heroin, and/or marijuana (AAP, 2012).

● Breastfeeding is not contraindicated with methadone use (AAP, 2012). Infants of mothers on methadone must be weaned gradually to avoid withdrawal.

● Women who smoke cigarettes should be advised to quit and be given information about cessation resources. Women who choose to continue to smoke should be taught to avoid smoking around the baby, to smoke immediately after breastfeeding and not before, and to cut down on the number of cigarettes that they smoke

122
Q

Follow up/discharge

A

● Comprehensive follow-up care for the mother or the foster mother before discharge. Infants exposed to substances prenatally often need long-term interdisciplinary physical and developmental care (Sherman, 2015b).

● Referrals must be made to the appropriate departments and agencies (Sherman, 2015b). In many health care settings, health care providers obtain a social service consult for women who have a history of substance use. Notification of agencies such as Child Protective Services is dependent on laws of each state. In some states, neonates who are positive for prenatal substance exposure are placed in foster care.

123
Q

Nursing actions-assess/review/monitor

A

● Review maternal history, including risk factors of substance use and history of current or past substance use.

● Assess the neonate, including gestational age.

● Assess for congenital anomalies and physical and behavioral signs of withdrawal/neonatal abstinence syndrome.

● Monitor vital signs.
● Use a scoring tool to assess for signs of withdrawal on neonates who are at high risk for neonatal abstinence syndrome (Fig. 17–8).

● Notify the physician if the score is outside of what is considered normal.

● The decision to treat with medication is based on the neonate’s score.

124
Q

Labs to obtain

A

● Obtain toxicology screening as per order.

● Clean-catch urine or meconium sample may be ordered.

125
Q

care for neonates with NAS

A

● Care for neonates experiencing neonatal abstinence syndrome:

● Assess feedings and daily weights: Increased activity, decreased sleep, irritability, loose stools, vomiting, and poor feeding behavior may all result in increased caloric needs.

● Provide frequent and small feedings: A higher calorie formula (22 to 24 cal/oz.) can be used to support increased caloric needs.

● Allow the neonate to rest during feedings.

● Position the neonate upright during feedings.

● Utilize nipples that have a slower flow if the neonate has a strong, frantic suck.

● Utilize gavage feedings if the neonate is unable to organize a productive suck.

● Provide a pacifier to the neonate.

● Bathe the baby in warm water to treat increased tone and irritability.

● Swaddle neonate with positioning that encourages flexion versus extension (Gomella, Cunningham, & Eyal, 2013).

● Minimize stimuli by providing a quiet environment, with lights dimmed.

● Be sensitive to infant cues that indicate stress; minimize stress-inducing activities.

● Rock the neonate gently (Sherman, 2015b).

126
Q

Care for the mother of a neonate with NAS

A

● Care for the mother of a neonate with neonatal abstinence syndrome:

● Provide nonjudgmental, honest, supportive care.

● Teach what to expect in regard to the neonate’s behavior. Educate about strategies that will provide comfort to her infant during withdrawal.

● Teach her how to feed her infant.

● Observe maternal–newborn interactions and involve the mother in the care of her newborn.

● Neonates who have been exposed to substances during the prenatal period often exhibit behaviors that interfere with the maternal–newborn relationship, such as irritability, resistance to being comforted, arching while being held, altered sleep states, poor feeding behavior, easily agitated when stimulated, and difficult transitions from one state to another.

● Characteristics of mothers with a history of substance abuse that may impair the maternal–newborn relationship include lack of sensitivity to infant cues, lack of emotional stability, lack of communication with the infant, and inconsistent/unavailable caregiving.

● Document all assessments and observations in the medical record per agency protocol