Unit 4 Newborn Care Chapter 23: Assessment and Management …libvolume7.xyz/nursing/bsc/4thyear/midwiferyandobstetricalnursing/... · Chapter 23: Assessment and Management of Newborn

4 1 2 MaternalNewbornNursing

Unit4 NewbornCare

Chapter23: AssessmentandManagementofNewbornComplications Contributor:LindaS.Wood,MSN,RN

NCLEX-PN®Connections:Learning Objective:Reviewandapplyknowledgewithin“Assessment and Management of Newborn Complications”inreadinessforperformanceofthefollowingnursingactivitiesasoutlinedbytheNCLEX-PN®testplan:

Checkthenewbornforpossiblecomplications.

Providecaretothenewbornwhoisexperiencingcomplications.

Newborn Complication: Preterm Infant

KeyPoints

Apreterminfantisonewhoisbornafter20weeksgestationandbeforethecompletionof37weeksgestation.

Preterm newborns areat risk fora variety of complications dueto immature organ systems. The degreeofcomplicationsdependsongestationalage.Thecloserthenewbornisto40weeksgestation,thelessthechancesareforcomplications.

Respiratory distress syndrome (RDS)–decreasedsurfactantinthealveoliregardlessofbirthweight.

Bronchopulmonary dysplasia (BPD)–causesthelungstobecomestiffandnoncompliant,requiringaninfanttobeplacedonmechanicalventilationandoxygen.Itissometimesdifficulttoremovetheinfantfromventilationandoxygenafterinitialplacement.

Aspiration–aresultoftheprematureinfantnothavinganintactgagreflexortheabilitytoeffectivelysuckorswallow.

Apnea of prematurity–aresultofimmatureneurologicalandchemicalmechanisms.

Intraventricular hemorrhage–bleedinginoraroundtheventriclesofthebrain.

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CHAPTER 23AssessmentandManagementofNewbornComplications

AssessmentandManagementofNewbornComplications

MaternalNewbornNursing 4 1 3

Retinopathyofprematurity–diseasecausedbyabnormalgrowthofretinalbloodvesselsandisacomplicationassociatedwithoxygenadministrationtotheneonate.Itcancausemildtosevereeyeandvisionproblems.

Patentductusarteriosus (PDA)–occurswhentheductusarteriosusreopensafterbirthduetoneonatalhypoxia.

Necrotizingenterocolitis (NEC)–aninflammatorydiseaseofthegastrointestinalmucosaduetoischemia.NECresultsinnecrosisandperforationofthebowel.Shortgutsyndromemaybetheresultsecondarytoremovalofmostorpartofthesmallintestineduetonecrosis.

Additional complicationsincludeinfection,hyperbilirubinemia,anemia,hypoglycemia,anddelayedgrowthanddevelopment.

KeyFactors

Preterm birthscanbeattributedtomanycausesincluding:

Gestationalhypertension.

Multiplepregnancies.

Adolescentpregnancy.

Lackofprenatalcare.

Substanceabuse.

Smoking.

Previoushistoryofpretermdelivery.

Abnormalitiesoftheuterus.

Cervicalincompetence.

Prematureruptureofthemembranes(PROM).

Placentaprevia.

DiagnosticandTherapeuticProceduresandNursingInterventions

Testsareperformedtomonitorforor treatthemanycomplicationsofpretermbirth.

Completebloodcount(CBC)showsdecreasedhemoglobinandhematocritasaresultoftheslowproductionofredbloodcells

Urinalysisandspecificgravity

Increasedprothrombintimeandpartialthromboplastintimewithanincreasedtendencytobleed

Chestx-ray

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Arterialbloodgas(ABG)

Headultrasounds

Echocardiography

Eyeexams

Serumglucose

Calcium

Bilirubin

DataCollection

Monitorfor signs and symptoms ofa preterm infant.

Ballard assessmentshowsaphysicalandneurologicalassessmenttotalinglessthan37weeksgestation

Periodic breathingconsistsof5to10secrespiratorypauses,followedby10to15seccompensatoryrapidrespirations

Signsofincreasedrespiratoryeffortand/orrespiratorydistress

Apnea(pauseinrespirationslongerthan10to15sec)

Lowbirthweight

Minimal subcutaneous fat deposits

Headlargeincomparisontobody

Wrinkledfeatures

Skinthatisthin,smooth,shiny,andmaybetranslucent

Veinsclearlyvisibleunderthin,transparentepidermis

Lanugooverthebody

Soft, pliable ear cartilage

Minimal creasesinthesolesandpalms

Skullandribcagefeelsoft

Closedeyesif22to24weeksgestation

Fewscrotalrugae

Undescendedtestes

Prominentlabiaandclitoris

Flatareolawithoutbreastbuds

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Weakgraspreflex

Heelsfullymovabletotheears, posture extended and frog-like

Inabilityto coordinate suck and swallow,andaweakorabsentgag,suck,andcoughreflex;weakswallow

Hypotonic muscles,decreasedlevelofactivity,weakcryformorethan24hr

Lethargy,tachycardia,andpoorweightgain

Signsofinfection

Observeforsignsofdehydration or overhydration(resultingfromIVnutritionandfluidadministration).

Dehydration

Urineoutputlessthan1mL/kg/hr

Urinespecificgravitymorethan1.015

Weightloss

Drymucousmembranes

Poorskinturgor

Depressedfontanel

Overhydration

Urineoutputgreaterthan3mL/kg/hr

Urinespecificgravitylessthan1.001

Edema

Increasedweightgain

Rales

Intakegreaterthanoutput

Assessmentsforprematureinfantsinclude:

Performingrapidinitialassessment.

Monitoringtheinfant’svitalsignsandtemperature.

Observingforcomplicationsofprematurity.

Assessingtheinfant’sabilitytoconsumeanddigestnutrients.Beforeaprematureinfantcanfeedbybreastornipple,theinfantmusthaveanintactgagreflexandbeabletosuckandswallowtopreventaspiration.

Monitoringtheinfant’sintakeandoutput.

Monitoringeliminationpatternsconsistingoffrequency,amount,color,andconsistency.

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Monitoringtheinfantforweightandfluidlossaswellasmeasuringandrecordingtheinfant’sweightdaily.

Monitoringforbleedingfrompuncturesitesandthegastrointestinaltract.

NANDANursingDiagnoses

Ineffectiveairwayclearancerelatedtoneuromusculardysfunction

Excessfluidvolumerelatedtointravenousnutrition

Suddeninfantdeathsyndromerelatedtoprematurityofinfant

Ineffectivethermoregulationrelatedtoinsufficientsubcutaneousbodyfat

Riskforinfectionrelatedtoimmatureimmunesystem

Riskfordisorganizedinfantbehaviorrelatedtoprematurityofinfant

NursingInterventions

Goalsincludemeetingtheinfant’sgrowthanddevelopmentneedsandanticipatingandmanagingassociatedcomplicationssuchasrespiratorydistresssyndromeandsepsis.

Themainpriorityintreatingpretermnewbornsissupportingthecardiacandrespiratorysystemsasneeded.Mostpreterminfantsarecaredforinaneonatalintensivecareunit(NICU).MeticulouscareandobservationintheNICUisnecessaryuntilthenewborncanreceiveoralfeedings,maintainbodytemperature,andweighsapproximately2kg(4.4lb).

Perform resuscitativemeasuresifneeded.

Ensure thermoregulation(neutralthermalenvironment)tomaintaintheprematureinfant’sbodytemperature

Administerrespiratorysupportmeasuressuchassurfactantand/oroxygenadministration.

Administerparental or enteral nutrition and fluidsasprescribed(mostprematureinfantslessthan34weekswillreceivefluidseitherbyIVorgavagefeedings).

Administermedicationsasprescribed.

Minimize stimulation.Clusternursingcare.Touchthenewbornverysmoothlyandlightly.Keeplightingdimandnoiselevelsreduced.

Positiontheinfantinneutral flexionwiththe extremities close to the bodytoconservebodyheat.Prone and side-lying positions are preferredtosupinewithbodycontainmentusingblanketrolls,swaddling,andsecureholdingtoprovidesecureboundaries.Pronepositionencouragesflexionoftheextremities.

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Providefornon-nutritive suckingsuchasusingapacifierwhilegavagefeeding.

Protectagainstinfection.

Keepparentsinformedandeducatedaboutthecareoftheirpretermnewborn.

Newborn Complication: Respiratory Distress Syndrome (RDS)

KeyPoints

Respiratory distress syndrome (RDS)occursasaresultofsurfactantdeficiencyinthelungsandischaracterizedbypoorgasexchangeandventilatoryfailure.

Surfactantisaphospholipidthatassistsinalveoliexpansion. Surfactantkeepsalveolifromcollapsingandallowsgasexchangetooccur.

Atelectasis(collapsingofaportionoflung)increasestheworkofbreathing.Asaresult,respiratoryacidosisandhypoxemiacandevelop.

Birth weight aloneisnotanindicatoroffetal lung maturity.

ComplicationsfromRDSarerelated to oxygen therapy and mechanical ventilation.

Pneumothorax

Pneumomediastinum

Retinopathyofprematurity

Bronchopulmonarydysplasia

Infection

Intraventricularhemorrhage

KeyFactors

Risk factorsthatcontributetoRDSinclude:

Decreasedgestationalage(preterm).

Perinatalasphyxia(e.g.,meconiumstaining,cordprolapse,andnuchalcord).

Maternaldiabetes.

Prematureruptureofmembranes.

Maternaluseofbarbituratesornarcoticsclosetobirth.

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Maternalhypotension.

Cesareanbirthwithoutlabor.

Hydropsfetalis(massiveedemaofthefetuscausedbyhyperbilirubinemia).

Maternalbleedingduringthethirdtrimester.


NewbornsdiagnosedwithRDSrequirespecificteststoevaluatetheirlungmaturity,abilitytoexchangegases,andcomplications.

ABGs revealhypercapnia(excessofcarbondioxideintheblood)andrespiratoryormixedacidosis.

Chestx-ray

Cultureandsensitivityoftheblood,urine,andcerebrospinalfluid

Bloodglucoseandserumcalcium

DataCollection

MonitorforsignsandsymptomsofRDS.

Increasedrespiratoryrategreaterthan60/min(tachypnea)

Intercostalandsubsternalretractions

Laboredbreathing

Fineralesonauscultation

Nasalflaring

Expiratorygrunting

Cyanosis

AsRDSworsens,theinfantmaybecomeunresponsive,flaccid,andapneic,withdecreasedbreathsounds.

AssessmentforRDSincludes:

Monitoringpulseoximetry.

Monitoringnutrition.

Monitoringvitalsignsclosely.

MonitoringIV.

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Impairedgasexchangerelatedtodeficientsurfactantorunderdevelopedalveoli

Riskforimpairedparent-infantattachmentrelatedtoRDSofinfantrequiringmedicalinterventions

Impairedspontaneousventilationrelatedtodecreasedsurfactantlevelsintheinfant’salveoli

Dysfunctionalventilatoryweaningresponserelatedtoinabilityoftheinfanttobreatheand/orcomplicationsassociatedwithtreatmentofthedisease

IneffectivecardiovasculartissueperfusionrelatedtoRDS


Factors that can accelerate lung maturation in the fetus while in utero includeincreasedgestationalage,intrauterinestress,exogenoussteroiduse,andrupturedmembranes.

NursinginterventionsforRDSintheinfantaremostlysupportive.

Suctiontheinfant’smouth,trachea,andnoseasneeded.

Maintainthermoregulation.

Administermedicationsasprescribed(e.g.,exogenoussurfactantinprematurity,naloxone[Narcan]inmaternalnarcoticuse).

Providemouthandskincare.

Correctrespiratoryacidosisbyventilatorysupport.

Correctmetabolicacidosisbyadministeringsodiumbicarbonate.

Maintainadequateoxygenation,preventlacticacidosis,andavoidtoxiceffectsofoxygen.

Decrease stimuli.

Offeremotionalsupporttotheparents.

Newborn Complication: Postterm Infant

KeyPoints

A postterm infant isonewhoisbornafterthecompletionof42weeksofgestation.Postmaturityoftheinfantcanbeassociatedwitheitherofthefollowing:

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Dysmaturity from placentaldegenerationanduteroplacentalinsufficiency(placentafunctionseffectivelyforonly40weeks)resultinginchronicfetalhypoxiaandfetaldistressinutero.Thefetalresponseispolycythemia,meconiumaspiration,andneonatalrespiratoryproblems.Perinatalmortalityishigherduetoincreasedoxygendemandsduringlabornotbeingmetbytheinsufficientplacenta.

Continued growth of the fetus in uterobecausetheplacentacontinuestofunctioneffectivelyandtheinfantbecomeslargeforgestationalageatbirth.Thisleadstoadifficultdelivery,cephalopelvic disproportion,aswellashighinsulinreservesandinsufficientglucosereservesatbirth.Theneonatalresponsecanbebirth trauma,perinatalasphyxia,aclaviclefracture,seizures,hypoglycemia,andtemperatureinstability(coldstress).

Apostmature infantmaybeeithersmall for gestational age (SGA) or large for gestational age (LGA)dependingonhowwelltheplacentafunctionsduringthelastweeksofthepregnancy.

Postmatureinfantshaveanincreased risk for aspirating the meconium passedbythefetusinutero.

Persistent pulmonary hypertension (persistent fetal circulation) isacomplicationthatcanresultfrommeconiumaspiration.Thereisaninterferenceinthetransitionfromfetaltoneonatalcirculation,andtheductusarteriosus(connectingmainpulmonaryarteryandtheaorta)andforamenovale(shuntbetweentherightandleftatria)remainopenandfetalpathwaysofbloodflowcontinue.

KeyFactors

Inmostcases,thecauseofaninfantgoingposttermisunknown,butthereisahigherincidenceinfirstpregnanciesandinwomenwhohavehadapreviousposttermpregnancy.


Cesareandelivery

Chestx-raytoruleoutmeconiumaspirationsyndrome

Bloodglucoselevelstomonitorforhypoglycemia

Arterialbloodgasessecondarytochronichypoxiainuteroduetoplacentalinsufficiency

Completebloodcountmayshowpolycythemiafromdecreasedoxygenationinutero

Hematocritelevatedfrompolycythemiaanddehydration

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DataCollection

Monitorsigns and symptoms of postterm infant.

Wastedappearance,thinwithlooseskin,havingusedsomeofthesubcutaneousfat

Peeling, cracked, and dry skin;leatheryfromdecreaseinprotectivevernixandamnioticfluid

Long,thinbody

Meconiumstainingoffingernails

Hairandnailsmaybelong

Maydemonstratemorealertnesssimilartoa2-week-oldinfant

Mayhavedifficultyestablishingrespirationssecondarytomeconiumaspiration

Signsandsymptomsofhypoglycemiaduetoinsufficientstoresofglycogen

Signsandsymptomsofcoldstress

Neurologicalsymptomsthatbecomeapparentwiththedevelopmentoffinemotorskills

Macrosomia

Nursing assessmentofthepostterm infantincludes:

Observingforbirthinjuryortrauma.

Respiratorystatus.

Reflexes.

Monitoringvitalsignsandtemperature.

Monitoringintravenousfluids.


Ineffectiveairwayclearancerelatedtomeconiumaspiration

Riskforaspirationrelatedtothepresenceofmeconium

Ineffectivethermoregulationrelatedtodecreasedsubcutaneousfat

NursingInterventionsNursinginterventionsforthepostterminfantinclude:

Assistingwithsurfactantlavagesduringdeliverytopreventmeconiumaspiration.

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Suctioningmeconiumfromtheneonate’smouthandnaresbeforethefirstbreath.

Usingmechanicalventilationifnecessary.

Administeringoxygenasprescribed.

Administeringintravenous fluids.

Preparingand/orassistingwithexchangetransfusionifhematocritishigh.

Providingthermoregulationinanincubatortoavoidcoldstress.

Providingearlyfeedingstoavoidhypoglycemia.

Identifyingandtreatinganybirthinjuries.

Newborn Complication: Large for Gestational Age Infant (LGA)/Macrosomic

KeyPoints

Large for gestational age (LGA)isaneonatewhoseweightisabove the 90thpercentileorweighing more than 4,000 g (8 lb, 12 oz).LGAneonatesmaybepreterm,postterm,orfullterm.LGAdoesnotnecessarilymeanpostmature.

Macrosomic infantsareatriskforbirthinjuries (e.g.,clavicle fractureoracesareanbirth,hypoglycemia,polycythemia).

Uncontrolledhyperglycemiaduringpregnancy(leadingriskfactorforLGA)canleadtocongenitaldefectswiththemostcommonbeingcongenitalheartdefects,tracheoesophagealfistula,andcentralnervoussystemanomalies.

KeyFactors

ContributingfactorsofanLGAinfantinclude:

Postterm infants.

Maternal diabetesduringpregnancy.Highglucoselevelsstimulatecontinuedinsulinproductionbythefetus.

Fetaldisorderoftranspositionofthegreatvessels.

Geneticfactors.

Obesity.

Multiparousmother.

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Cesareandeliveryifnecessary

Chest x-raytoruleoutmeconiumaspirationsyndrome

Blood glucose levels tomonitorcloselyforhypoglycemia(lessthan40mg/dL)

Arterialbloodgasesmaybeprescribedduetochronichypoxiainuterosecondarytoplacentalinsufficiency

CBCshowspolycythemia(hematocritgreaterthan65%)frominuterohypoxia

Hyperbilirubinemiaresultingfrompolycythemiaasexcessiveredbloodcellsbreakdownafterbirth

Hypocalcemiamayresultinresponsetoalonganddifficultbirth

DataCollection

MonitorLGAinfantsfor:

Weight above 90th percentile (4,000 g).

Plumpandfull-faced(cushingoidappearance)fromincreasedsubcutaneousfat.

Signsofhypoxia.

Birth trauma(e.g.,fractures,intracranialhemorrhage,andcentralnervoussysteminjury).

Sluggishness,hypotonic muscles,andhypoactivity.

Tremorsfromhypocalcemia.

Signsandsymptomsofhypoglycemia.

Signsandsymptomsofrespiratorydistressfromimmaturelungsormeconiumaspiration.

NursingassessmentforLGAinfantsinclude:

Observingforinjury.

Reflexes.

Earlyandfrequentglucoselevels.


Auscultatinglungsounds.

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Riskforinjurysuchasaclaviclefracturerelatedtobirthtrauma

Riskforperipheralneurovasculardysfunctionrelatedtoinjurysustainedduringbirth

Impairedphysicalmobilityrelatedtoparalysisoffacialorbrachialnervesustainedduringbirthinjury

Ineffectivetissueperfusionrelatedtohypoglycemia


Nursing interventions foranLGAinfantinclude:

Obtainingearlyandfrequentheelsticks(glucosetesting).

Providingearlyfeedingsorintravenoustherapytomaintainnormalglucoselevels.

Thermoregulationwithincubatorcare.

Administeringsurfactantbyendotrachealtubeifindicated.

Identifyingandtreatinganybirthinjuries.

Newborn Complication: Hypoglycemia

KeyPoints

Hypoglycemiaisaserumglucoselevelofless than 40 mg/dL.Routineassessmentofallnewborns,especiallyLGAinfants,shouldincludeobservingforsymptomsofhypoglycemia.

Hypoglycemia–differsforthepretermandtermnewborn.Hypoglycemiaoccurringinthefirst3daysoflifeinthetermnewbornisdefinedasabloodglucoselevelof<40mg/dL.Inthepretermnewborn,hypoglycemiaisdefinedasthebloodglucoselevelof<25mg/dL.

Untreated hypoglycemiacanresultinmental retardation.

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KeyFactors

Maternaldiabetes

Preterminfant

LGA

Stressatbirthsuchascoldstressandasphyxia

Maternalepiduralanesthesia


Twoconsecutivelowplasmaglucoselevelslessthan40mg/dLintheterminfant,lessthan25mg/dLinthepreterminfant

DataCollection

Monitorforsignsandsymptomsofhypoglycemia.

Poorfeeding

Jitteriness/tremors

Hypothermia

Diaphoresis

Weakshrillcry

Lethargy

Flaccidmuscletone

Seizures/coma

Nursing assessmentsforhypoglycemiainclude:

Monitoringbloodglucoselevelclosely.

MonitoringIVifunabletoorallyfeed.

Monitoringforsignsofhypoglycemia.


NANDANursingDiagnosesDisproportionategrowthoftheneonaterelatedtomaternaldiabetes

Imbalancednutrition:Lessthanbodyrequirementsrelatedtopoorfeeding

Riskforinjuryrelatedtocentralnervoussystemcomplicationsofhypoglycemia

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Nursing interventionsforhypoglycemiainclude:

Obtainingbloodperheelstickforglucosemonitoring.

Frequentoraland/orgavagefeedingsorcontinuosparenteralnutrition isprovidedearlyafterbirthtotreathypoglycemia(untreatedhypoglycemiacanleadtoseizures,braindamage,anddeath).

Newborn Complication: Small for Gestational Age Infant (SGA)/Intrauterine Growth Restriction (IUGR)

KeyPoints

Small for gestational age (SGA) describesaninfantwhosebirthweightisat or below the 10th percentile.

Common complications ofSGAinfantsareperinatalasphyxia,meconiumaspiration,hypoglycemia,polycythemia,andinstabilityofbodytemperature.

KeyFactors

Factors thatcontribute toanewbornbeingSGAinclude:

Congenitalorchromosomalanomalies.

Maternalinfections,disease,ormalnutrition.

Gestationalhypertensionand/ordiabetes.

Smoking,drug,oralcoholuse.

Multiplegestations.

Placentalfactors(e.g.,smallplacenta,placentaprevia,decreasedplacentalperfusion).

Fetalcongenitalinfectionssuchasrubellaortoxoplasmosis.


Chestx-raytoruleoutmeconiumaspirationsyndrome

Bloodglucoselevelforhypoglycemia

CBCwillshowpolycythemiaresultingfromfetalhypoxiaandintrauterinestress

ABGsmaybeprescribedduetochronichypoxiainuteroduetoplacentalinsufficiency

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DataCollection

MonitorforsignsandsymptomsofSGA/IUGR.

Weight below 10th percentile

Normalskull,butreducedbodydimensions

Reducedsubcutaneousfat

Loose,dryskin

Decreasedmusclemassparticularlyoverthecheeksandbuttocks

Drawnabdomenratherthanwell-rounded

Thin,dry,yellow,anddullumbilicalcordratherthangray,glistening,andmoist

Scalphairsparse

Wideskullsuturesfrominadequatebonegrowth

Signsofrespiratorydistressandhypoxia

Wide-eyed and alert attributed to prolonged fetal hypoxia

Signsofmeconiumaspiration

Signsofhypoglycemia

Signsofhypothermia

Nursing assessmentsforSGA infantsinclude:

Auscultatingbreathsounds.

Pulseoximetry.

Assessingaxillaryskintemperatureevery4hr.

Cardiovascularcirculation.

Signsoffatigueorrespiratorydistress.

Signsofskinbreakdown.



Impairedgasexchangerelatedtoaspirationofmeconium

Ineffectivethermoregulationrelatedtodecreasedsubcutaneousfat

Imbalancednutrition:Lessthanbodyrequirementsrelatedtoincreasedmetabolicrate

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Nursing interventionsforSGA/IUGRinfantsinclude:

Supporting respiratory effortsandsuctioning asnecessarytomaintainanopenairway.

Providinganeutralthermalenvironment(isoletteorradiantheatwarmer)toprevent cold stress.

Initiatingearly feedings (SGAwillhavemorefrequentfeedings).

Parenteralnutritionifnecessary.

Administeringapartial exchange transfusion toreduceviscosityofthebloodifprescribed.

Maintainingadequate hydration.

Conservinganewborn’senergylevel.

Preventingskinbreakdown.

Protectingfrominfection.

Providingsupporttoparentsandextendedfamilyandencouragingthemtoparticipateinnewborncare.

Newborn Complication: Hyperbilirubinemia

KeyPoints

Hyperbilirubinemiaisanelevation of serum bilirubin levelsresultinginjaundice.Jaundicenormallyappearsinacephalocaudalmanner,firstbeingnoticedinthehead(especiallythescleraandmucousmembranes),andthenprogressesdownthethorax,abdomen,andextremities.

Jaundice can be either physiologic or pathologic

Physiologicjaundice isconsideredbenign(resultingfromnormalnewbornphysiologyofincreasedbilirubinproductionduetotheshortenedlifespanandbreakdownoffetalRBCsandliverimmaturity).Theinfantwithphysiologicaljaundicehasnoothersymptomsandshowssignsofjaundice after 24 hr of age.

Pathologicjaundiceisaresultofanunderlyingdisease.Pathologicjaundiceappearsbefore 24 hr of ageorispersistent after day 7.Intheterminfant,bilirubinlevelsincreasemorethan0.5mg/dL/hr,peaksatgreater than 13 mg/dL,orisassociatedwithanemiaandhepatosplenomegaly.Pathologicjaundiceisusuallycausedbyabloodgroupincompatibilityoraninfection,butmaybetheresultofRBCdisorders.

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Kernicterus(bilirubinencephalopathy)canresultfromuntreatedhyperbilirubinemiawithbilirubin levels at or higher than 25 mg/dL.Itisaneurologicalsyndromecausedbybilirubindepositinginbraincells.Survivorsmaydevelopcerebralpalsy,epilepsy,ormentalretardation.Theymayhaveminoreffectssuchaslearningdisordersorperceptual-motordisabilities.

KeyFactors

Factors that affect development of hyperbilirubinemiainclude:

IncreasedRBCproductionorbreakdown.

Rh or ABO incompatibility.

Decreasedliverfunction.

Maternalenzymesinbreastmilk.

Ineffectivebreastfeeding.

Certainmedications(aspirin,tranquilizers,andsulfonamides).

Hypoglycemia.

Hypothermia.

Anoxia.


Laboratorytestingincludes:

Elevated serum bilirubin level(directandindirectbilirubin).Monitortheinfant’sbilirubinlevelsevery4hruntillevelreturnstonormal.

Bloodgroupincapabilitybetweenthemotherandnewborn.

Hemoglobinandhematocrit.

Direct Coombs’ testrevealsthepresenceofantibody-coated(sensitized)Rh-positiveRBCsinthenewborn.

Electrolytelevelsfordehydrationfromphototherapy.

Phototherapyistheprimarytreatmentofhyperbilirubinemia.

DataCollection

Monitorforsignsandsymptomsofjaundicedifferentiatingbetweenpathologicandphysiologicjaundice.

Noteyellowishtinttoskin,sclera,andmucousmembranes.

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Toverifyjaundice,presstheinfant’sskinonthecheekorabdomenlightlywithonefinger,thenreleasepressureandobserveskincolorforyellowishtintastheskinisblanched.

Notetimeofjaundiceonsettodistinguishbetweenphysiologicandpathologicjaundice.

Assesstheunderlyingcausebyreviewingthematernalprenatal,family,andnewbornhistory.

Signsofhypoxia,hypothermia,hypoglycemia,andmetabolicacidosiscanoccurasaresultofhyperbilirubinemiaandincreasetheriskofbraindamage.

Monitorforsignsandsymptomsofkernicterus.

Yellowishskin

Lethargy

Hypotonic

Poorsuck

Ifuntreated,theinfantwillbecomehypertonicwithbackwardarchingoftheneckandtrunk

High-pitchedcry

Fever

Nursing assessments forhyperbilirubinemiainclude:

Observingskinandmucousmembranesforsignsofjaundice.

Monitoringvitalsigns.

Observeforside effects of phototherapy.

Bronzediscoloration,notaseriouscomplication

Maculopapularskinrash,notaseriouscomplication

Developmentofpressure areas

Dehydration(e.g.,poorskinturgor,drymucousmembranes,decreasedurinaryoutput)

Elevated temperature

Nursing assessments duringphototherapyinclude:

Monitoringeliminationandweighingdaily,watchingforsignsofdehydration.

Checkingaxillarytemperatureevery4hrduringphototherapybecausetemperaturemaybecomeelevated.

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Riskforinjuryrelatedtohemolyticdiseaseandeffectsofphototherapy

Deficientknowledge(parents)relatedtohyperbilirubinemiaandtreatment


Nursing interventionsforhyperbilirubinemiainclude:

Feedingearlyandfrequently – every3to4hr.Thiswillpromotebilirubinexcretioninthestools.

Maintainingadequatefluidintaketopreventdehydration.

Reassuringtheparentsthatmostnewbornsexperiencesomedegreeofjaundice.

Explaininghyperbilirubinemia,causes,diagnostictests,andtreatmenttoparents.

Explainingthatthenewborn’sstoolcontainssomebilethatwillbeloose andgreen.

Settingupphototherapyifprescribed.

Maintainingeye maskoverthenewborn’seyesforprotectionofcorneasandretinas.

Keepingthenewborn undressedwiththeexceptionofamalenewborn.Asurgicalmaskshouldbeplaced(makelikeabikini)overthegenitaliatopreventpossibletesticulardamagefromheatandlightwaves.Besuretoremovethemetalstripfromthemasktopreventburning.

Not applying lotions or ointmentstotheinfantbecausetheyabsorbheatandcancauseburns.

Removing the newborn from phototherapy every 4 hr andunmaskingthenewborn’seyesandcheckingforsignsofinflammationorinjury.

Repositioning the newborn every 2 hrtoexpose all of the body surfacestothephototherapylightsandprevent pressure sores.

Turningoffphototherapylightsbeforedrawingbloodfortesting.

Administeringanexchange transfusionforinfantsatriskforkernicterus.

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Newborn Complications: Congenital Anomalies

KeyPoints

Newbornscanbebornwithamultitudeofcongenital anomaliesinvolvingallsystems.Theseareoftendiagnosedprenatally.Anurseshouldprovideemotionalsupporttotheparentswhoarefacingproceduresorsurgeriestocorrectthedefects.

Congenital anomaliesarepresentatbirthandcaninvolveanyofthebodysystems.Majoranomaliescausingseriousproblemsinclude:

Congenital heart disease(atrialseptaldefects,ventricularseptaldefects,coarctationoftheaorta,tetralogyofFallot,transpositionofthegreatvessels,stenosis,atresiaofvalves).

Neurological defects(neuraltubedefects,hydrocephalus,anencephaly,encephalocele,meningocele,ormyelomeningocele).

Gastrointestinal problems(cleftlip/palate,diaphragmatichernia,imperforateanus,tracheoesophagealfistula/esophagealatresia,omphalocele,gastroschisis,umbilicalhernia,orintestinalobstruction).

Musculoskeletal deformities(clubfoot,polydactyly,developmentaldysplasiaofthehip).

Genitourinary deformities(hypospadias,epispadias,exstrophyofthebladder).

Metabolic disorders(phenylketonuria,galactosemia,hypothyroidism).

Chromosomal abnormalities (e.g.,Downsyndrome,whichisthemostcommontrisomicabnormalitywith47chromosomesineachcell).

KeyFactors

Risk factorsforcongenital anomaliesincludegeneticand/orenvironmentalfactors.

Maternalagegreaterthan40years

ChromosomeabnormalitiessuchasDownsyndrome

Viralinfectionssuchasrubella

Excessivebodyheatexposureduringthefirsttrimester(neuraltubedefects)

Medicationsandsubstanceabuseduringpregnancy

Radiationexposure

Maternalmetabolicdisorders(e.g.,phenylketonuria,diabetesmellitus)

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Poormaternalnutritionsuchasfolicaciddeficiency(neuraltubedefects)

Prematureinfants

SGAinfants

Oligohydramniosorpolyhydramnios


Prenatal diagnoses of congenitalanomaliesareoftenmadebyamniocentesis,chorionicvillisampling,ultrasound,andalphafetalprotein.

Routine testingofnewbornsformetabolicdisorders(inbornerrorsofmetabolism)

Guthrietestforphenylketonuria(PKU)showingelevationsofphenylalanineinbloodandurine.Notreliableuntiltheinfanthasingestedsufficientamountsofprotein.

Bloodandurinelevelsofgalactose(galactosemia)

Thyroxinemeasurement(hypothyroidism)

Cytologic studies(karyotypingofchromosomes)suchasabuccalsmearusescellsscrapedfromthemucosafrominsideofthemouth.

Dermatoglyphicsexaminesthepatternsformedbytheridgesintheskinonthedigits,palms,andsoles(Downsyndrome).

Congenitalanomaliesaregenerallyidentified soon after birthbyApgarscoringandabriefassessmentindicatingtheneedforfurtherinvestigation.Onceidentified,congenitalanomaliesaretreated in a pediatric setting.

DataCollection

Monitorforsignsandsymptomsofcongenital anomaliesincluding:

Cleft lip/palate –failureoftheliporhardorsoftpalatetofuse.

Tracheoesophageal atresia–failureoftheesophagustoconnecttothestomach,excessivemucoussecretionsanddrooling,periodiccyanoticepisodesandchoking,abdominaldistentionafterbirth,andimmediateregurgitationafterbirth.

Phenylketonuria (PKU)–theinabilitytometabolizetheaminoacidphenylalanine;canresultinmentalretardationifuntreated.

Galactosemia –inabilitytometabolizegalactoseintoglucose.Canresultinfailuretothrive,cataracts,jaundice,cirrhosisoftheliver,sepsis,andmentalretardationifuntreated.

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Hypothyroidism – slowmetabolismcausedbymaternaliodinedeficiencyormaternalantithyroidmedicationsduringpregnancy.Canresultinhypothermia,poorfeeding,lethargy,jaundice,andcretinismifuntreated.

Neurologic anomalies (spina bifida) –aneuraltubedefectinwhichthevertebralarchfailstocloseandtheremaybeaprotrusionofthemeningesand/orspinalcord.

Hydrocephalus–excessivespinalfluidaccumulationintheventriclesofthebraincausingtheheadtoenlargeandthefontanelstobulge.Sun-settingsigniscommoninwhichthewhitesoftheeyesarevisibleabovetheiris.

Patent ductus arteriosus (PDA)–noncyanoticheartdefectinwhichtheductusarteriosusconnectingthepulmonaryarteryandtheaortafailstocloseafterbirth.Signsandsymptomsconsistofmurmurs,abnormalheartrateorrhythm,breathlessness,andfatiguewhilefeeding.

Tetralogy of Fallot–cyanoticheartdefectcharacterizedbyaventricularseptaldefect,theaortapositionedovertheventricularseptaldefect,stenosisofthepulmonaryvalve,andhypertrophyoftherightventricle.Observeforsignsofrespiratorydifficulties,cyanosis,tachycardia,tachypnea,anddiaphoresis.

Down syndrome–obliquepalpebralfissuresorupwardslantofeyes,epicanthalfolds,flatfacialprofilewithadepressednasalbridgeandasmallnose,protrudingtongue,smalllow-setears,shortbroadhandswithafifthfingerthathasoneflexioncreaseinsteadoftwo,adeepcreaseacrossthecenterofthepalmfrequentlyreferredtoasasimiancrease,hyperflexibility,andhypotonicmuscles.

Nursing assessmentsofinfantswithcongenital anomaliesinclude:

Newborn’sabilitytotakeinadequatenourishment.

Newborn’sabilitytoeliminatewasteproducts.

Vitalsignsandaxillarytemperature.

Infant-parentalbonding,observingtheparent’sresponsetothediagnosisofacongenitaldefect,andencouragingtheparentstoverbalizeconcerns.


Riskforimpairedparentingrelatedtocongenitalanomalyofinfant

Riskforinjuryordeathrelatedtocongenitalanomaly

Riskforinfectionrelatedtocongenitalanomalyoritstreatment

Dysfunctionalgrievingrelatedtothebirthofaninfantwithacongenitalanomaly

Deficientknowledgerelatedtocongenitalanomalyanditstreatment

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Nursinginterventionsforcongenitalanomaliesaredependentuponthetypeandextentoftheanomaly.

Neurologic anomalies (spina bifida)

Protectmembranewithsterilecoveringandplastictopreventdrying.

Observeforleakageofcerebrospinalfluid.

Handlenewborngentlybypositioningproneortothesidetopreventtrauma.

Preventinfectionbykeepingfreefromcontaminationbyurineandfeces.

Measurethecircumferenceoftheheadtoidentifyhydrocephalus.

Assessforincreasedintracranialpressure.

Hydrocephalus

Frequentlyrepositiontheinfant’sheadtopreventsores.

Measuretheinfant’sheadcircumferencedaily.

Assesstheinfantforsignsofincreasedintracranialpressuresuchasvomitingandashrillcry.

PDA

Educatetheparentsaboutthetreatmentofsurgery.

Tetralogy of Fallot

Conservetheinfant’senergytoreducetheworkloadontheheart.

Administergavagefeedingsorgiveoralfeedingswithaspecialnipple.

Elevatetheinfant’sheadandshoulderstoimproverespirationsandreducethecardiacworkload.

Preventinfection.

Placetheinfantinaknee-chestpositionduringrespiratorydistress.

Nursinginterventionsforcongenitalanomaliesinclude:

Establishingandmaintainingadequaterespiration.

Establishingextrauterinecirculation.

Establishinggoodthermoregulation.

Providingadequatenutrition.

Cleft lip/palate–determinethemosteffectivenippleforfeeding.Feedtheinfantintheuprightpositiontodecreaseaspirationrisk.Feedslowly,burpingfrequentlysecondarytotendencytoswallowair.Cleansethemouthwithwaterafterfeedings.

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Tracheoesophageal atresia–withholdfeedingsuntilthedeterminationofesophagealpatency.Elevatetheheadofthecribtopreventgastricjuicereflux.Supervisethefirstfeedingofallnewbornstoobserveforthisanomaly.

PKU –specialsyntheticformulainwhichphenylalanineisremovedorreduced.Restrictionofmeat,dairyproducts,dietdrinks,andprotein.Aspartamemustbeavoided.

Galactosemia –giveinfantamilksubstancebecausegalactoseispresentinmilk.

Administeringmedicationsasprescribedsuchasthyroidreplacementforhypothyroidism.

Educatingtheparentsregardingpreoperativeandpostoperativetreatmentprocedures.

Encouragingtheparentstohold,touch,andtalktotheirnewborn.

Ensuringthattheparentsprovideconsistentcaretothenewborn.

Newborn Complication: Birth Trauma or Injury

KeyPoints

Birth injury consistsofaphysicalinjurysustainedbyanewbornduringlaboranddelivery.Mostinjuriesareminorandresolverapidly.Otherinjuriesmayrequiresomeintervention.Afewareseriousenoughtobefatal.

Types of birth injuries include:

Scalp(e.g.,caputsuccedaneum,cephalohematoma).

Skull(e.g.,linearfracture,depressedfracture).

Intracranial(e.g.,epiduralorsubduralhematoma,cerebralcontusion).

Spinalcord(e.g.,spinalcordtransactionorinjury,vertebralarteryinjury).

Plexus(e.g.,totalbrachialplexusinjury,Klumpkeparalysis).

Cranialandperipheralnerve(e.g.,radialnervepalsy,diaphragmaticparalysis).

KeyFactors

Maternal, intrapartum, obstetric birth techniques, and newborn factors maypredispose the newborn to injuries.Theseinclude:

Fetalmacrosomia.

Abnormalordifficultpresentations.

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Uterinedysfunctionleadingtoprecipitateorprolongedlabor.

Cephalopelvicdisproportion.

Multifetalgestation.

Congenitalabnormalities.

InternalFHRmonitoring.

Forcepsorvacuumextraction.

Externalversion.

Cesareanbirth.


BirthinjuriesarenormallydiagnosedbyCTscan,x-rayofsuspectedareaoffracture,orneurologicalexamtodetermineparalysisofnerves.

DataCollection

Monitorthenewbornforsignsandsymptomsofbirthinjuries,whichinclude:

Irritability,seizures,anddepression.Theseareallsignsofasubarachnoidhemorrhage.

Facialflatteningandunresponsivenesstogrimacethataccompaniescryingorstimulation,andtheeyeremainingopenaresymptomstoassessforfacialparalysis.

Weakorhoarsecry,whichischaracteristicoflaryngealnervepalsyfromexcessivetractionontheneck.

Flaccidmuscletone,whichmaysignaljointdislocationsandseparationduringbirth.

Flaccidmuscletoneoftheextremities,whichissuggestiveofnerveplexusinjuriesorlongbonefractures.

Limitedmotionofanarm,crepitusoveraclavicle,andabsenceofMororeflexontheaffectedside,whicharesymptomsofclavicularfractures.

Flaccidarmwiththeelbowextendedandthehandrotatedinward,absenceoftheMororeflexontheaffectedside,sensorylossoverthelateralaspectofthearm,andintactgraspreflex,whicharesymptomsofErb-Duchenneparalysis(brachial paralysis).

Localizeddiscoloration,ecchymosis,petechiae,andedemaoverthepresentingpart.Theseareseenwithsofttissueinjuries.

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Nursingassessmentsforbirthinjuriesinclude:

Reviewingmaternalhistoryandlookingforfactorsthatmaypredisposethenewborntoinjuries.

Apgarscoring thatmightindicateapossibilityofbirthinjury.Neonatesinneedofimmediateresuscitationshouldbeidentified.

Initial head to toe physical assessment andcontinued assessment uponeachcontactwiththeneonate.

Vital signsandtemperature.


Injuryrelatedtobirthtrauma

Impairedphysicalmobilityrelatedtobrachialplexusinjury

Impairedgasexchangerelatedtodiaphragmaticparalysis

Acutepainrelatedtoinjury


Nursing interventionsforbirth injuriesinclude:

Administeringtreatmenttothenewbornbasedontheinjuryandaccordingtotheprimarycareprovider’sprescriptions.

Preventingfurthertraumabydecreasingstimuliandmovement.

Educatingtheinfant’sparentsandfamilyregardingtheinjuryandthemanagementoftheinjury.

Promotingparent-newbornbonding.

Newborn Complication: Neonatal Infection/Sepsis (Sepsis Neonatorum)

KeyPoints

Infectionmaybecontractedbythenewbornbefore,during,orafterdelivery.Newbornsaremoresusceptibletomicro-organismsbecauseoftheirlimitedimmunityandinabilitytolocalizeinfection.Theinfectioncanthereforespreadrapidlyintothebloodstream.

Neonatal sepsisisthepresenceofmicro-organismsortheirtoxinsinthebloodortissuesoftheinfantduringthefirstmonthafterbirth.Signsofsepsisaresubtleandmayresembleotherdiseases;thenurseoftennoticesthemduringroutinecareoftheinfant.

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Prevention of infectionand neonatal sepsisstartsperinatallywithmaternalscreeningforinfections,prophylacticinterventions,andtheuseofsterileandaseptictechniquesduringdelivery.Prophylacticantibiotictreatmentoftheeyesofallnewbornsandappropriateumbilicalcordcarealsohelptopreventneonatalinfectionandsepsis.

KeyFactors

Risk factorsforinfection/sepsisofthenewborninclude:

Prematureruptureofthemembranes.

TORCH(toxoplasmosis,rubella,cytomegalovirus,andherpes).

Chorioamnionitis.

Prematurebirth.

Lowbirthweight.

Substanceabuse.

Maternalurinarytractinfection.

Meconium.

Humanimmunodeficiencyvirus(HIV)transmittedfromthemothertothenewbornperinatallythroughtheplacentaandpostnatallythroughthebreastmilk.


Complete septic workupincludes:

CBC.

Blood,urine,andcerebrospinalfluidculturesandsensitivities.

Positive blood cultures,usuallypolymicrobial(morethanonepathogen)indicatesthepresenceofinfection/sepsis.

Organismsfrequentlyresponsibleforneonatalinfectionsinclude:Staphylococcus aureus,S. epidermidis, Escherichia coli, Haemophilus influenza, and group B Streptococcus.

Chemical profileshowsafluid and electrolyte imbalance.

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DataCollection

Monitorforsignsandsymptomsofneonatal infection/sepsis, whichinclude:

Temperatureinstability.

Suspiciousdrainage(e.g.,eyes,umbilicalstump).

Poorfeedingpattern,suchasaweaksuckordecreasedintake.

Vomitinganddiarrhea.

Poorweightgain.

Abdominaldistention,largeresidualiffeedingbygavage.

Apnea,sternalretractions,grunting,andnasalflaring.

Decreasedoxygensaturation.

Colorchangessuchasjaundice,pallor,andpetechiae.

Tachycardiaorbradycardia.

Poormuscletoneandlethargic.

Nursing assessmentsforneonatal infection/sepsisinclude:

Assessinginfectionrisks(reviewmaternalrecord).

Monitoringforsignsofopportunisticinfection.

Monitoringvitalsignscontinuously.

Axillarytemperature.

Pulseoximetry.

Assessingforweightloss.

Monitoringfluidandelectrolytestatus.

Monitoringvisitorsforinfection.


Infectionrelatedtomaternalinfection,needforindwellingintrauterinedevices,orneonatalcontactwithpathogen

Ineffectivethermoregulationrelatedtoinfection

Impairedtissueintegrityrelatedtoinvasiveprocedures

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Nursing interventionsforneonatal infections/sepsisinclude:

Obtaining specimens(blood,urine,andstool)toassistinidentifyingthecausativeorganism.

InitiatingandmaintainingIV therapyasprescribedtoadministerelectrolytereplacements,fluids,andmedications.

Administeringmedicationsasprescribed(e.g.,broad-spectrumantibioticspriortoculturesbeingobtained).

Initiatingandmaintainingrespiratory supportasneeded.

Providingnewborncaretomaintain temperature.

Maintainingstandardprecautions.

Cleaningandsterilizingallequipmenttobeused.

Providingfamilyeducationoninfectioncontrol,whichincludes:

Instructingthefamilyontheuseofcleanbottlesandnipplesforeachfeeding.

Notstoringleftoverformula.

Supervisinghandwashing.

Providingemotionalsupporttothefamily.

Newborn Complication: Maternal Substance Abuse During Pregnancy

KeyPoints

Maternal substance abuse during pregnancyconsistsofanyuseofalcoholordrugsduringpregnancy.Intrauterinedrugexposurecancauseanomalies,neurobehavioralchanges,andsignsofwithdrawal.Thesechangesdependonspecificdrugorcombinationofdrugsused,dosage,routeofadministration,metabolismandexcretionbymotherandfetus,timingofdrugexposure,andlengthofdrugexposure.

Substance withdrawalinthenewbornoccurswhenthemotherusesillicitdrugswhilepregnant.

Fetal alcohol syndrome (FAS)resultsfromthechronicorperiodicintakeofalcoholduringpregnancy.Alcoholisconsideredteratogenic,sothedailyintakeofalcoholincreasestheriskofFAS.

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NewbornswithFASareatriskforspecificcongenitalphysicaldefects,alongwithlong-termcomplicationsincluding:

Feedingproblems.

Centralnervoussystemdysfunction(e.g.,mentalretardation,cerebralpalsy).

Behavioraldifficultiessuchashyperactivity.

Languageabnormalities.

Futuresubstanceabuse.

Delayedgrowthanddevelopment.

Poormaternal-infantbonding.

KeyFactors

Risk factorsformaternal substance abuse during pregnancyinclude:

Motherusingsubstancespriortoknowingsheispregnant.

Maternalsubstanceabuseandaddiction.


Drug screenofurineormeconiumtorevealtheagentabusedbythemother.

Chest x-rayforFAStoruleoutcongenitalheartdefects.

Blood testsshouldbedonetodifferentiatebetweenneonataldrugwithdrawalandcentralnervoussystemirritability.Testsshouldinclude:

CBC.

Bloodglucose.

Calcium.

Magnesium.

TSH,T4,T3.

ABS.

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DataCollection

Monitorforsignsandsymptomsofneonatal abstinence syndrome(withdrawal)intheneonateusingtheneonatal abstinence scoring systemthatassessesforandscoresthefollowing:

Central nervous systems–irritability,tremors,high-pitched,shrillcry,incessantcrying,hyperactivewithincreasedMororeflex,increaseddeeptendonreflexes,increasedmuscletone,increasedwakefulness,excoriationsonthekneesandface,andconvulsions.

Metabolic, vasomotor, and respiratory–nasalcongestionwithflaring,tachypnea,sweating,frequentyawning,skinmottling,tachypneagreaterthan60/min,temperaturegreaterthan37.2°C(99°F).

Gastrointestinal–poorfeeding,vomiting,regurgitation(projectilevomiting),diarrhea,andexcessive,uncoordinated,andconstantsucking.

Opiatewithdrawalcanlastfor2to3weeks.

Signsandsymptomsofneonatalabstinencesyndrome includerapidchangesinmood,hypersensitivitytonoiseandexternalstimuli,dehydration,andpoorweightgain.

Heroin withdrawal

SignsandsymptomsofneonatalabstinencesyndromeincludelowbirthweightandSGA,decreasedMororeflexes(ratherthanincreased),andhypothermiaorhyperthermia.

Methadone withdrawal

Signsandsymptomsofneonatalabstinencesyndromeincludeanincreasedincidenceofseizures,higherbirthweights,andhigherriskofsuddeninfantdeathsyndrome.

Marijuana withdrawal

Signsandsymptomsincludepretermbirthandmeconiumstaining.

Amphetamine withdrawal

PretermorSGA,drowsiness,jitters,respiratorydistress,frequentinfections,poorweightgain,emotionaldisturbances,anddelayedgrowthanddevelopment.

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Fetal alcohol syndrome

Facialanomaliesincludeeyeswithepicanthalfolds,strabismus,andptosis;mouthwithapoorsuck,cleftliporpalate,andsmallteeth

Deafness

Abnormalpalmarcreasesandirregularhair

Manyvitalorgananomaliessuchasheartdefectsincludingatrialandventricularseptaldefects,teratologyofFallot,andpatentductusarteriosus

Developmentaldelaysandneurologicabnormalities

Prenatalandpostnatalgrowthretardation

Sleepdisturbances

Tobacco

Prematurity,lowbirthweight,increasedriskforsuddeninfantdeathsyndrome,increasedriskforbronchitis,pneumonia,anddevelopmentaldelays

Nursing assessments formaternal substance abuse andneonatal effects or withdrawal include:

Apgarscoring.

Headtotoephysicalassessment.

Elicitingandassessingreflexes.

Monitoringinfant’sabilitytofeedanddigestintake.

Monitoringfluidsandelectrolytessuchasskinturgor,mucousmembranes,fontanels,andI&O.

Observingtheinfant’sbehavior.

Vitalsignsandtemperature.

Measuringandweighingoftheneonate.

Observingparent-infantbonding.


Riskforinjuryrelatedtohyperactivityorseizures

Alterednutrition:Lessthanbodyrequirementsrelatedtopoorsuckreflex

Riskfordeficientfluidvolumerelatedtovomitinganddiarrhea

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Nursing interventionsfortheeffects on the neonate of substance abuse during pregnancyorsubstance withdrawal include:

Administeringmedicationsasprescribedtodecrease central nervous systemirritabilityandcontrolseizures.

Reducing external stimulation.

Swaddlingthenewbornsnugglytoreduceselfstimulationandprotecttheskinfromabrasions.

Frequent, small feedingsofhigh-calorieformula–mayneedgavagefeedings.

Elevating theinfant’s headduringandfollowingfeedings,andburping the infantwelltoreducevomitingandaspiration.

Tryingvariousnipplestocompensateforapoorsuckreflex.

Havingsuctionavailabletoreducetheriskforaspiration.

Forcocaine addicted infants, avoiding eye contactandusingvertical rockingandapacifier.

Preventinginfection.

Referringmothertoadrugand/oralcoholtreatmentcenter.

PrimaryReference:Lowdermilk,D.L.&Perry,S.E.(2004).Maternity & women’s health care(8thed.).St.

Louis,MO:Mosby.

AdditionalResources:NANDAInternational(2004).NANDA nursing diagnoses: Definitions and

classification 2005-2006.Philadelphia:NANDA.

Pillitteri,A.(2003).Maternal & child health nursing: Care of the childbearing and childrearing family(5thed.).Philadelphia:Lippincott.

Springhouse(2003). Maternal-neonatal nursing made incredibly easy! (1sted.).Philadelphia:Lippincott,Williams,&Wilkins.

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Chapter23:AssessmentandManagementofNewbornComplications

ApplicationExercises

Scenario:Anurseiscalledtothebirthingroomtoassistwiththeassessmentofa32-weekgestationnewbornandtoprovidecaretothemotherpostpartum.Theinfant’sbirthweightis1,100g.Theinfant’sApgarscoresare3at1minand7at5min.Theinfantisexperiencingnasalflaring,grunting,andsubsternalandintercostalretractions.Heisflaccidandlyinginafrog-likeposition.Theinfantiscoveredwithathick,cheesysubstance(vernixcaseosa),andlanugoiswidelydistributedoverhisbody.

1.Whichofthefollowingarecharacteristicsofapreterminfantthatthenursemayseeatthisbirth?(Selectallthatapply.)

_____ Largeheadincomparisontobody

_____ Lanugo

_____ Longhair

_____ Longnails

_____ Weakgraspreflex

_____ Translucentskin

_____ Plumpface

2.Whatassessmentfindingsindicatethatacomplicationmaybedevelopingforthisnewborn?

3.Whyisthisinfantatriskforineffectivethermoregulation?

4.Anurseiscaringforaninfantwithahighbilirubinlevelwhoisreceivinghighintensitylighttreatments(phototherapy).Thenurse’shighestassessmentpriorityinmonitoringthisinfantistocheckfrequentlyandcarefullyforsignsofwhichofthefollowingcommonandpotentialseriouscomplicationsofphototherapy?

A.Retinaldamage

B.Bronzeskindiscoloration

C.Dehydration

D.Maculopapularskinrash



5.Anurseassessesatermnewborndeliveredlessthan1hrago.Thenursesuspectsaproblembasedontheinfant’s

A.relaxedposture.

B.clenchedfists.

C.startlereaction.

D.steppingmovements.

6.Amultiparouswomanat40weeksofgestationhasjustgivenbirthtohernewborn.Afterprolongedpushinginthesecondstage,aforceps-assistedbirthwasnecessary.Thenewbornweighs9lb,8oz(4,318g).Thenewbornhasmarkedcaputsuccedaneumandmarkedbruisingabouttheface,head,andshoulders.Howwouldanursecharacterizethisinfant?(Selectallthatapply.)

_____ Preterm

_____ Term

_____ Postterm

_____ LGA

_____ SGA

_____ AGA

7.Anurseisexamininganinfantwhowasjustdeliveredtoawomanat41weeksgestation.Whichofthefollowingcharacteristicsindicatesthatthisinfantispostterm?

A.Abundantlanugo

B.Flatareolawithoutbreastbuds

C.Heelsmovablefullytotheears

D.Leathery,cracked,wrinkledskin



8.ToevaluatetheefficacyofsyntheticsurfactantgiventoapreterminfantdiagnosedwithRDS,thenurse’sfirstpriorityinassessmentismonitoringtheinfant’s

A.oxygensaturation.

B.bodytemperature.

C.bilirubinlevels.

D.heartrate.

9.Anurseshouldconsiderthepossibilityofneonatalwithdrawalsyndromeifanewborn

A.hasdecreasedmuscletone.

B.hasacontinuoushigh-pitchedcry.

C.sleepsfor2hrafterfeeding.

D.hasmildtremorswhendisturbed.

10.Theparentofapostterminfantisconcernedbecausehisinfant’sskinisdryandpeeling.Whichofthefollowingresponsesbythenurseismostappropriate?

A.“Thistypeofskinisanexpectedfindinginbabiesbornafter42weeksofgestation.”

B.“Itwouldbebestforyoutoaskthepediatricianabouttheconditionofyourbaby’sskin.”

C.“Peelingskiniscommoninsomefamilies.Haveyouseenthisinotherinfantsinyourfamily?”

D.“Don’tworry.Wehaveseveralskinpreparationswecanapplytohelpresolvethiscondition.”

11.Anewbornisdeliveredat39weeks.Theneonatalnurseplotstheinfant’sweightandfindsittobeinthe8thpercentileforweight.Thisinfantwouldbeclassifiedas

A.termandAGA.

B.pretermandLGA.

C.termandSGA.

D.posttermandSGA.

12.Whichofthefollowingnutritionalproblemsshouldthenurseobserveforinapretermneonate?

A.Hypoglycemia

B.Hyperglycemia

C.Anemia

D.Galactosemia



Chapter23:AssessmentandManagementofNewbornComplications

ApplicationExercisesAnswerKey

Scenario:Anurseiscalledtothebirthingroomtoassistwiththeassessmentofa32-weekgestationnewbornandtoprovidecaretothemotherpostpartum.Theinfant’sbirthweightis1,100g.Theinfant’sApgarscoresare3at1minand7at5min.Theinfantisexperiencingnasalflaring,grunting,andsubsternalandintercostalretractions.Heisflaccidandlyinginafrog-likeposition.Theinfantiscoveredwithathick,cheesysubstance(vernixcaseosa),andlanugoiswidelydistributedoverhisbody.

1.Whichofthefollowingarecharacteristicsofapreterminfantthatthenursemayseeatthisbirth?Selectallthatapply.

__X__ Large head in comparison to body

__X__ Lanugo

_____ Longhair

_____ Longnails

__X__ Weak grasp reflex

__X__ Translucent skin

_____ Plumpface

Characteristics of a preterm infant include large head in comparison to body, lanugo over the body, a weak grasp reflex, and skin that is thin, smooth, shiny, and may be translucent. Long hair and nails are signs of a postterm infant. A plump face would be seen in a macrosomic infant.

2.Whatassessmentfindingsindicatethatacomplicationmaybedevelopingforthisnewborn?

Nasal flaring, grunting, and substernal and intercostal retractions indicate that the infant is experiencing respiratory distress. The frog-like position, vernix caseosa, and lanugo are the usual assessment findings for a premature newborn at 32 weeks gestation.



3.Whyisthisinfantatriskforineffectivethermoregulation?

The infant’s low birth weight and gestational age mean that it has little glycogen stored in its liver and little brown fat available for producing heat. The preterm infant lacks subcutaneous fat to insulate his body and his flaccid muscle tone does not allow him to take a flexed position to prevent heat loss.

4.Anurseiscaringforaninfantwithahighbilirubinlevelwhoisreceivinghighintensitylighttreatments(phototherapy).Thenurse’shighestassessmentpriorityinmonitoringthisinfantistocheckfrequentlyandcarefullyforsignsofwhichofthefollowingcommonandpotentialseriouscomplicationsofphototherapy?

A.Retinaldamage

B.Bronzeskindiscoloration

C. Dehydration

D.Maculopapularskinrash

Infants receiving phototherapy lose more water and have loose stools due to increased bilirubin excretion. This increases their risk of dehydration, a serious and sometimes life-threatening complication in an infant. Supplemental oral or intravenous fluids are given as needed to prevent this complication. It is not known whether or not phototherapy causes retinal damage; nevertheless, it is standard procedure to protect the infant’s eyes by closing them and then covering them with eye patches while the infant is exposed to phototherapy. Due to the confinement of the patches, it is important for the nurse to assess the infant’s eyes between therapy sessions for signs of conjunctivitis. However, the nurse would not be able to detect signs of retinal damage during routine assessments. Some infants who have elevated direct serum bilirubin levels develop a bronze discoloration as a side effect of phototherapy. This is not a serious complication. Infants can also develop a maculopapular skin rash as a side effect of phototherapy. Again, this is not a serious complication. Because the infant’s opportunities to be held are limited, the nurse must assess the infant’s skin carefully for development of pressure areas and must change the infant’s position at least every 2 hr.



5.Anurseassessesatermnewborndeliveredlessthan1hrago.Thenursesuspectsaproblembasedontheinfant’s

A. relaxed posture.

B.clenchedfists.

C.startlereaction.

D.steppingmovements.

A relaxed position indicates hypotonia, which is a possible result of hypoxia in utero or medications received by the mother. The nurse would expect to find fist clenching in a newborn. Straightened legs that are not flexed at the knees are an expected finding following a breech presentation. The nurse should review the delivery record before concluding that this finding represents a problem. It is expected that a newborn’s legs would move one at a time as though the infant were pedaling a bicycle.

6.Amultiparouswomanat40weeksofgestationhasjustgivenbirthtohernewborn.Afterprolongedpushinginthesecondstage,aforceps-assistedbirthwasnecessary.Thenewbornweighs9lb,8oz(4,318g).Thenewbornhasmarkedcaputsuccedaneumandmarkedbruisingabouttheface,head,andshoulders.Howwouldanursecharacterizethisinfant?(Selectallthatapply.)

______ Preterm

__X__ Term

______ Postterm

__X__ LGA

______ SGA

______ AGA

The infant is term (40 weeks) and LGA (greater than 90th percentile in weight). Preterm is prior to 37 weeks gestation and postterm is after the completion of the 42nd week of gestation. SGA is an infant that is at or below the 10th percentile in weight. AGA is between the 10th and 90th percentile for weight.



7.Anurseisexamininganinfantwhowasjustdeliveredtoawomanat41weeksgestation.Whichofthefollowingcharacteristicsindicatesthatthisinfantispostterm?

A.Abundantlanugo

B.Flatareolawithoutbreastbuds

C.Heelsmovablefullytotheears

D. Leathery, cracked, wrinkled skin

Leathery, cracked, and wrinkled skin is seen in a postterm newborn due to placental insufficiency. Abundant lanugo, flat areolas without breast buds, and heels movable fully to ears are found in preterm newborns.

8.ToevaluatetheefficacyofsyntheticsurfactantgiventoapreterminfantdiagnosedwithRDS,thenurse’sfirstpriorityinassessmentismonitoringtheinfant’s

A. oxygen saturation.

B.bodytemperature.

C.bilirubinlevels.

D.heartrate.

Surfactant contains surface-active phospholipids, specifically lecithin and sphingomyelin, that are critical for alveolar stability. Surfactant therapy stabilizes the alveoli and prevents collapse, thereby increasing lung compliance and maintaining or improving oxygen saturation. Surfactant would not have a direct effect on body temperature, thus it would not reflect the efficacy of this treatment. However, cold stress increases the amount of oxygen the newborn needs. Hypothermia in a newborn can lead to metabolic acidosis, hypoxia, and shock. The nurse must provide a neutral thermal environment for this infant and monitor body temperature continuously. Surfactant does not have a direct effect on bilirubin levels; however, preterm infants are prone to hyperbilirubinemia and so this parameter must be monitored and treated as needed. However, serum bilirubin level is not a reflection of the efficacy of surfactant. It is important to monitor the heart rate of any preterm infant, as well as any infant who has RDS. Since surfactant can cause bradycardia, this is an especially important assessment parameter for this infant. However, heart rate is not a reflection of the efficacy of surfactant therapy.



9.Anurseshouldconsiderthepossibilityofneonatalwithdrawalsyndromeifanewborn

A.hasdecreasedmuscletone.

B. has a continuous high-pitched cry.

C.sleepsfor2hrafterfeeding.

D.hasmildtremorswhendisturbed.

Symptoms of withdrawal from maternal substance abuse include central nervous system disturbances such as an excessive or continuous high-pitched cry and a markedly hyperactive Moro reflex. An infant withdrawing from narcotics or other substances abused maternally is likely to have an increased muscle tone along with other central nervous system disturbances. Most newborns sleep for varying amounts of time after feeding. Symptoms of withdrawal from maternal substance abuse include difficulty moving through various sleep stages. These infants might only sleep for very short periods of time. This sleep pattern disturbance is related to central nervous system excitation secondary to drug or alcohol withdrawal. Many newborns have mild tremors when they are disturbed. What distinguishes infants who have neonatal abstinence syndrome from this normal pattern is that they have moderate to severe tremors when they are undisturbed.

10.Theparentofapostterminfantisconcernedbecausehisinfant’sskinisdryandpeeling.Whichofthefollowingresponsesbythenurseismostappropriate?

A. “This type of skin is an expected finding in babies born after 42 weeks of gestation.”

B.“Itwouldbebestforyoutoaskthepediatricianabouttheconditionofyourbaby’sskin.”

C.“Peelingskiniscommoninsomefamilies.Haveyouseenthisinotherinfantsinyourfamily?”

D.“Don’tworry.Wehaveseveralskinpreparationswecanapplytohelpresolvethiscondition.”

Peeling skin is a normal condition seen in postterm newborns due to dehydration from placental insufficiency. There is no need to ask the primary care provider as this is a normal finding in postterm newborns. A condition of peeling skin in the family would not show up as early as the newborn period. Lotions will not help with the peeling because it is due to lack of nutrition. The peeling will resolve once the newborn receives adequate nutrition and fluids.



11.Anewbornisdeliveredat39weeks.Theneonatalnurseplotstheinfant’sweightandfindsittobeinthe8thpercentileforweight.Thisinfantwouldbeclassifiedas

A.termandAGA.

B.pretermandLGA.

C. term and SGA.

D.posttermandSGA.

This newborn is term, between 37 and 42 weeks gestation, SGA, and below the 10th percentile.

12.Whichofthefollowingnutritionalproblemsshouldthenurseobserveforinapretermneonate?

A. Hypoglycemia

B.Hyperglycemia

C.Anemia

D.Galactosemia

A preterm neonate is at risk for hypoglycemia because it has not built up glycogen reserves yet. A preterm infant will have polycythemia and excessive red blood cells rather than anemia. Galactosemia is the inability of the neonate to convert galactose to glucose and is an inborn error of metabolism.

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Unit 4 Newborn Care Chapter 23: Assessment and Management …libvolume7.xyz/nursing/bsc/4thyear/midwiferyandobstetricalnursing/... · Chapter 23: Assessment and Management of Newborn