1
Q
the majority of high-risk infants are born in _____ weeks?
A
less than 37 weeks
(preterm)
2
Q
organ systems of preterm infants are __
A
immature and lack adequate reserves of bodily nutrients
3
Q
potential problems and care needs of a preterm infant weighing 2000g differ from ____
A
potential problems and care needs of a preterm infant weighing 2000g differ from those of a term, post term or postmature infant of equal weight
4
Q
high-risk newborn classification factors
A
- birth weight
- gestational age
- predominant pathophysiologic problems
5
Q
extremely low-birth weight
A
1000g/2.2lb or less
6
Q
very low-birth weight
A
less than1500g/3.3lbs
7
Q
low-birth weight (LBW)
A
2500g/5.5lbs or less
8
Q
very premature (GA)
A
less than 32 weeks
9
Q
premature (GA)
A
born between 32 and 34 weeks
10
Q
late premature (GA)
A
born between 34 and 37 weeks
11
Q
tone and flexion of preterm infant
A
- increased with greater GA
- early in gestation, resting tone and posture are hypotonic and extended
12
Q
skin of preterm infant
A
- translucent
- transparent
- red
13
Q
subcutaneous fat of preterm infant
A
decreased
14
Q
lanugo of preterm infant
A
- present between 20 and 28 weeks
- at 28 weeks GA, lanugo begins to disappear on the face and the front of the trunk
15
Q
foot creases of preterm infant
A
- not present until 28-30 weeks
- plantar creases increase and spread toward the heel of the foot as GA increases
16
Q
eyelids of preterm infant
A
- fused in very preterm
- eyelids open between 26-30 weeks gestation
17
Q
overriding sutures of preterm infants
A
- common among premature, LBW infants
18
Q
pinna of preterm infants
A
- thin
- soft
- flat
- folded
19
Q
eyelids open between ___-___ weeks gestation
A
- eyelids open between 26-30 weeks gestation
20
Q
foot creases are present at what GA?
A
between 28-30 weeks
21
Q
lanugo is present at what GA?
A
between 20-28 weeks
22
Q
nursing actions for preterm infants
A
- look at general appearance
- respiratory and cardiovascular support
- maintain neutral thermal environment (NTE)
- nutrition
- fluid and electrolytes
- involving parents
- tests and procedures
23
Q
cardiovascular assessment
A
- HR
- HR rhythm
- murmurs
- skin color
- pulses
- capillary refill
24
Q
how to provide cardiovascular support
A
- monitor BP, O2 sat, and blood gas
- obtain and monitor hemoglobin and hematocrit per order
- administer blood transfusion per order
25
fluid and electrolyte balance: nurse actions
- monitor I&O by weighing diapers- 1g=1ml
- assess frequency, color, amount, SG to determine hydration
- record intake from IV fluids
- restrict fluids per order
- monitor electrolyte levels
- administer IV fluids per order
- add humidity to environment to decrease fluid loss through the skin
26
nutrition: nurse actions
- monitor blood glucose
- administer feeds (trophic, parenteral, enteral)
27
trophic feeding
- small volume enteral feedings
28
parenteral feeding
- for infants below 32 weeks
- IV feedings
29
enteral feeding
- administered orally or by gastric tubes
- can be given via GI tract
30
signs of respiratory distress syndrome
- tachypnea (RR above 60)
- nasal flaring
- grunting
- intercostal or subcostal retractions
- skin color is gray or dusky
- decreased breath sounds
- lethargic and hypotonic
- tachycardia (HR above 160)
31
L/S ratio
ratio between the two phospholipids provides information on the level of surfactant (maturity of lungs)
- non-diabetic mom: 2:1 ratio indicates mature fetal lungs
- diabetic mom: 3:1 ratio indicates mature fetal lungs
32
what is bronchopulmonary dysplasia/who does it affect?
- chronic lung infection
- affects neonates who have been treated with mechanical ventilators and oxygen for problems like RDS
33
what can bronchopulmonary dysplasia lead to?
- decreased lung compliance and pulmonary function secondary to:
- fibrosis,
- atelectasis,
- increased pulmonary resistance,
- overdistention of the lungs
34
who is at an increased risk for BPD?
- neonates who are dependent on oxygen beyond 28 days of life
and/or
- have been mechanical ventilation
35
what is an intravascular hemorrhage?
- bleeding around the ventricles of the brain
- common among very low birth weight babies (1500g)
36
intravascular hemorrhage: sudden changes in condition
- bradycardia
- increased oxygen requirements
- hypotonia
- metabolic acidosis
- shock
- decreased hematocrit
- full and/or tense anterior fontanel*
- hyperglycemia
37
intravascular hemorrhage: s/ bleeding is worsening
- apnea
- increased need for ventilator support
- drop in BP
- acidosis
- seizures
- full and tense fontanels and rapid increase in head size
- diminished activity or LOC
38
what is necrotizing enterocolitis (NEC)?
- a gastrointestinal disease that affects neonates that results in inflammation and necrosis of the bowel
39
NEC assessment/sx
- abdominal distention
- visibile bowel loops
- emesis
- bloody stools
- abnormal VS- hypotensive, temp instability
- tender belly
- green vomit
40
what increases the chances for medical management of NEC?
early recognition
41
nurse actions for NEC
- withhold feedings per orders and obtain IV access
- perform gastric decompression per orders by placing an orogastric tube and connecting it to low suction
- monitor I&O
- maintain circulating blood volume
- maintain adequate hydration
- prepare neonate and family for surgery when indicated (reanastomosis)
42
retinopathy of prematurity (ROP)
- common in premature neonates
- occurs because the retina is not completely vascularized and is susceptible to stress or injury
43
what can result from retinopathy of prematurity?
blindness
44
risk factors of retinopathy of prematurity
- high levels of O2
- premature
45
decreasing the risk of retinopathy of prematurity includes
- continuous monitoring of oxygen to maintain prescribed pulse oximetry parameters
- careful use of oxygen during procedures such as suctioning
- use of equipment such as oxygen blenders to ensure the exact concentration of oxygen
- properly maintaining and calibrating oxygen systems
46
post-term infant
- born > 41 weeks
- 4-14% of births
47
risk factors of post-term infants
- anencephaly
- hx of post-term
- first pregnancy
- grand multiparous women
48
complications of post-term infant
- Hypoglycemia
- Fetal hypoxia
- Meconium aspiration
- Neuro complications – seizures
- Cold stress due to diminished SC FAT!!
- Polycythemia R/T ↓ perfusion of “older placenta” leads to ↑ production of RBC’s.
- More RBC’s leads to hyperbilirubinemia
- Cephalohematoma and/or Caput succedaneum
- Birth Trauma from macrosomia
49
meconium aspiration syndrome (MAS)
- Aspiration of meconium into tracheo-bronchial tree during 1st few breaths after delivery
- Causes obstruction of air flow → ↓oxygenation, potential atelectasis and pneumothorax
50
s/sx of MAS
- low APGAR scores
- grunting
- flaring
- retracting with decreased breath sounds
- barrel chest
51
MAS interventions/nurse actions
- Assist with suctioning and resuscitation at delivery
- Assess for respiratory distress
- Assess for neuro problems
- Administer O2
- Monitor blood glucose
- Manage cooling systems used to reduce cerebral injury
52
MAS complications
- pneumothorax
- infection
- pneumonia
- PPHN
53
pneumothorax
collection of air outside the lungs but within the pleural cavity
- between visceral and parietal pleura inside the chest
54
persistent pulmonary hypertension (PPHN) of the newborn
- results when the normal vasodilation and relaxation of the pulmonary vascular bed do not occur
- need to involve parents, keep them informed
55
PPHN leads to
- elevated pulmonary vascular resistance
- right ventricular hypertension
- right-to-left shunting of blood through the foramen ovale and ductus arteriosus
56
PPHN risk factors
- Hypoxia and Asphyxia (most common)
- Low APGAR scores
- RDS, MAS, Pneumonia
- Sepsis
- Delayed circulation – delayed resuscitation
- Congenital problems
57
SGA and IUGR
- Defined as weight is below the <10th percentile expected at term
- Symmetric IUGR
- Asymmetric IUGR
58
symmetric IUGR
- generalized proportional reduction in the size of all structures and organs except for heart and brain, occurs early in pregnancy and affects general growth
- can be identified via ultrasound in early 2nd trimester
59
Asymmetric IUGR
- a disproportional reduction in size of structures and organs, results from maternal or placental conditions that occur later in pregnancy and impede placental blood flow
60
SGA/IUGR interventions/nurse actions
- Assess for meconium at delivery
- Assess temperature
- Provide NTE
- Assess for hypoglycemia
- Weigh daily
- Strict I&O
61
SGA/IUGR risk factors
- Multiple gestation
- Age- below 15 or above 45
- No prenatal care
- Low weight gain
- Substance abuse
- Preeclampsia
- Chronic hypertension
- Affects girls more than boys
- Rubella
- Toxoplasmosis
- Cytomegalovirus
62
SGA/IUGR placental problems
- Small placentas
- Abnormal cord insertion
- Placenta previa
- Abruptio placenta
63
the IUGR infant characteristics
- large head
- loose skin dry with little-no fat
- little scalp hair
- weak cry
64
complications of the IUGR infant
- Perinatal asphyxia
- Hypothermia
- Hypoglycemia
- Polycythemia - ↑ RBC’s- infant looks ruddy
- Growth and cognitive difficulties
65
nurse actions for the IUGR infant
- Assess for respiratory distress
- Maintain a neutral thermal environment
- Decrease risk of hypoglycemia
- provide early feeds
- Monitor glucose levels
- Weigh daily
- Monitor vital signs
- Monitor for feed intolerances
- Teach parents the importance of keeping warm and providing frequent feeds
66
LGA infant
- Defined as weight > 90th percentile at full term
- Macrosomia: infant weighs > 4000 grams at birth
- Have greater body length and head size
67
macrosomia
infant weighs > 4000 grams at birth
68
LGA risk factors
- Maternal diabetes
- Multiparity
- Previous macrosomia baby (hx)
- Prolonged pregnancy
69
LGA leads to
- Cesarean births
- Operative vaginal delivery
- Shoulder dystocia
- Breech presentation
- Birth trauma
- Cephalopelvic disproportion
- Hypoglycemia**
- Hyperbilirubinemia
70
complications of LGA (think injuries)
- fractured clavicle
- brachial plexus is stretched due to traction
71
infants of diabetic moms are at risk for
- Congenital anomalies- especially cardiac defects
- Skeletal defects
- Placental insufficiency leading to IUGR and perinatal asphyxia-
- Neurological problems R/T lack of glucose to lack of brain glucose
- Risk of childhood obesity
72
infants of diabetic moms: assessment findings
- Macrosomia
- Fractured clavicle – brachial nerve injury
- Hypoglycemia
- Polycythemia
- Low muscle tone
- Poor ability to feed
- Respiratory distress
73
nurse actions for infants of diabetic moms
- Assess for physical characteristics and identify maternal history of diabetes (gestational, insulin dependent, diet controlled)
- Monitor for symptoms of hypoglycemia
-Monitor glucose screening Q 30 minutes after birth & then one hour after that
-Feed q3 hours & check glucose AC (before) feeding
-Assess for symptoms of hypoglycemia: jitteriness, tremors, temperature instability, lethargy, & poor feeder
-Give 40% dextrose gel in buccal cavity (if BS below <40)
-10% dextrose and water IV
- Assess for signs of respiratory distress (grunting, flaring, retracting, tachypnea)
74
neonatal infection
- The immune system of a neonate is immature, placing the infant at risk for infection during the first several months of life.
- Depending on the type of infection, neonates may be asymptomatic at birth and develop symptoms within a 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).
75
way of transmitting or acquiring an infection
- vertical transmission
- transplacental transfer
- ascending infection
- intrapartal exposure
76
what is the leading cause of morbidity and mortality of neonates?
- Infections among neonates are a leading cause of morbidity and mortality
- immature immune systems at birth
77
neonatal infection assessment findings: respiratory
- apnea
- grunting
- retractions
- tachypnea
- cyanosis
78
neonatal infection assessment findings: thermo
- hypothermia
- fever
- temp instability
79
neonatal infection assessment findings: cardio
- bradycardia
- tachycardia
- arrhythmias
- hypotension
- decreased perfusion
80
neonatal infection assessment findings: neuro
- tremors
- lethargy
- irritability
- high pitched cry
- hypotonia
- hypertonia
- seizures
- bulging fontanelles
81
neonatal infection assessment findings: GI
- poor feeding
- vomiting
- diarrhea
- abdominal distention
- enlarged liver/spleen
82
neonatal infection assessment findings: skin
- rash
- pustules
- vesicles
- pallor
- jaundice
- petechiae
83
neonatal infection assessment findings: metabolic
- hypoglycemia
- metabolic acidosis
84
group beta strep (GBS)
- bacterial infection
- a leading cause of neonatal morbidity and mortality in the US
85
substance abuse exposure
- effects of perinatal maternal substance abuse is related to the substance used
- can have both short and long-term consequences
- neonatal abstinence syndrome
86
neonatal abstinence syndrome (definition)
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
87
substance abuse exposure: respiratory s/sx
- Irregular respirations
- Tachypnea
- nasal congestion
- Grunting
- Flaring
88
substance abuse exposure: neurologic s/sx
- Irritability
- tremors
- shrill cry
- incessant crying
- hypertonicity
89
substance abuse exposure: gastrointestinal s/sx
- Frantic sucking
- Incessant hunger
- Diarrhea leading to skin breakdown
90
substance abuse exposure: autonomic dysfunction s/sx
- Sneezing
- yawning
- Fever leads to sweating
- mottled skin
91
nursing care of infant in withdrawal
- Observe for signs of distress – sneezing, coughing, gave aversion; hiccups – swaddle and hold as needed in a flexed position → wrap snuggly and hold tightly
- Keep in a quiet, darkened room – reduce stimuli
- Use pacifier to meet the need for excessive sucking
- Feed frequently in small amounts; ↑ HOB after feeds and burp well – “spitty”
- Medicate as ordered
- Supportive therapy for nutrition and electrolyte balance; respiratory
- Encourage bonding with parents
- Parental support and education
92
omphalocele
Defect in the umbilical ring with the peritoneal sac covers the protruding defect
- normally before 11 weeks GA, the organs stick out from the abdomen because of their growth. if they do not go back into the abdomen and close up, then the omphalocele forms
- needs surgical repair, abdominal contents returned gradually
93
omphalocele: nurse management
- Cover viscera with moist sterile saline gauze with plastic wrap.
- Repogle tube for stomach decompression
- Place in a prone or side-lying position
- Support viscera
- Prevent insensible water loss
-Biggest concerns are infection and fluid/electrolyte balance
94
gastroschisis
herniation of the bowel through a defect in the abdominal wall to the right of the umbilical cord
- needs surgical repair
95
what is the difference between an omphalocele and gastroschisis
- omphalocele is sealed by the perineum (sealed in the O)
- gastroschisis: abdominal contents are not covered by the perineum (come out of the G)
96
spina bifida
- NTD
- a birth defect that occurs when the spine and spinal cord don't form properly
- A sack with the meninges and cerebrospinal fluid bulge through a defect in the undeveloped vertebrae
- Surgical repair is necessary
97
assisting with grief
- Being present and allowing them to express their feelings
- Express empathy and condolences
- Refer to the baby by name
- Give them time with their baby
- Give them memorabilia such as blanket, hair, hat, bracelets
- Offer to contact the Chaplin, Priest (whatever religion is)
- Discuss plans with the family- autopsy, cremation, burial
- Encourage family to accept help and give resources
- not just the lost of a baby, loss of a future
- this includes parents caring for a child with special needs
98
when should women be screened for GBS
- 35-37 weeks
- if positive treat with antibiotics in labor
99
Pregnant women who were GBS + or who had a pregnancy before where baby tested positive for GBS
- Treat in the intrapartum period with penicillin
- no test required
100
if GBS is unknown at the time of rupture or at the time of labor onset
- if 18h ROM, less than 37 weeks, temp 100.4
-treat prophylatically ***
101
GBS+ women with a planned c/s
- treat with Azithromycin if labor or ROM is present prior to the operation
102
what is the drug of choice with GBS?
penicillin G
- IV until delivery
- 5mu initially then 2.5mu q4h
103
neonates born to treated GBS+ moms
don't get antibiotics unless symptomatic
104
babies born to treated moms less than 35 weeks that are asymptomatic
get routine blood cultures and CBC
105
any infant with signs of GBS infection
- get blood cultures and immediate antibiotics, CBC, and chest x-ray
106
full-term infants who received 4 hours of antibiotics and are asymptomatic
can go home in 24 hours as long as asymptomatic and treated with 2 doses of PCN in labor
107
how would you describe rudiness?
- think excessive RBC
- very red
108
fluid/electrolyte assessment
I&Os
109
breastmilk decreased the risk for what in infants?
decreases the risk of necrotizing enterocolitis
110
atelectasis is
alveoli of lungs collapse
- can be caused by underdevelopment
- not enough surfactant
111
critical importance of respiratory system
maintaining NTE environment
- cover infant
- dry when wet
- remove wet towels
112
nursing actions of the respiratory system
- maintain patent airway
- admin O2- hypoxemia and acidosis may further decrease surfactant production
- minimize oxygen demand by maintaining NTE, clustering care to decrease stress, and treating acidosis
- suction the airway as needed
- maintain the NTE to decrease risk of cold stress
- monitor I&O and daily weights
113
fibrosis
scarring in the lungs
114
what is the issue with cold stress (in regard to O2 consumption/respiratory system)
- cold stress increases O2 consumption, which prompts acidosis and may further impair surfactant production
115
why hold feedings with a NEC baby
- infection or dead bowel
116
how fatal is NEC
20-30%
117
babies that weigh under 1000g/2.2lbs are at a ____(%) risk of developing ROP
babies that weigh under 1000g are at an 80% risk of developing ROP
118
post-term infant physical characteristics
dry peeling nails
stained skin
creases in feet are very pronounced
119
polycythemia is
too many RBC
excess RBC cause blood to increase in volume and thicken- doesn't flow as easily
- think jaundice/hyperbilirubinemia
120
cephalohematoma
- does NOT cross the suture lines
- involves bone
- not seen at birth
- slowly resolves- 3 weeks
- no skin color change
121
caput suc
- crosses suture lines
- seen at birth- vacuum babies
- involves scalp only
- seen at birth
- skin ecchymosis
- resolves spontaneously
- common cause of jaundice
122
MAS is a cause of ____
respiratory failure
- result of relaxation of the external anal sphincter in utero- causes meconium to enter the lungs
123
patent ductus arteriosus (PDA)
- heart murmur heard at the upper left sternal boarder
- active precordium (visible movement of the heart contracting on the patient's left chest)
- bounding pulses
- widened pulse pressure
- tachycardia and tachypnea
- recurrent apnea increased work of breathing
- increased demand for oxygen or ventilation
- difficulty weaning from the ventilator support
124
in fetal circulation (in utero), the DA shunts blood in what direction?
shunts blood away from the lungs
- they aren't using their lungs in utero, so they don't need blood in lungs
125
do all infants with PDA have an audible murmur?
no, not all have audible murmurs
126
asymmetrical IUGR is also called
head sparing
127
how do nurse assessments generally go when assessing a newborn (any system/any situation)?
start general, then go head to toe
128
ascending exposure
infection the ascends into the uterus r/t prolonged rupture of membranes
129
intrapartal exposure
exposed to infection during the birth process
- i.e. GBS+ mom
130
horizontal transmission
infections transferred from hospital staff or equipment to the neonate (HAIs)
131
transplacental exposure
infection transmitted through the placenta
132
what do we suggest pregnant women take to prevent NTDs (spina bifida)?
600 mcg Folic Acid
133
what determines how impactful spina bifida is to the newborn?
how high up the sac of meninges and cerebrospinal fluid is
- the higher up the more impactful
134
what is cryptorchidism?
undescended testicles
- sometimes descends naturally, sometimes needs surgical assistance
- rare in full term babies
135
what could happen if cryptorchidism is left untreated
testicular cancer
- because the hormones are not where they are supposed to be
136
cardiovascular consequences of umbilical cord clamping
- increase in arterial pressure and cerebral blood flow
- decrease in venous return and decrease in ventricular preload
- decrease in R and L ventricular output (as much as 50%)
137
risk of perinatal brain injury is decreased if ____
lungs can be aerated and ventilation has commenced before umbilical cord clamping
138
physiologic factors (during birth) that affect blood flow after birth
- positioning of baby (above or below the placenta)
- uterine contractions (improves umbilical circulation)
139
early cord clamping (definition)
- the application of a clamp across the umbilical cord while there is still significant circulation occurring through the umbilical vessels
- clamping cord within 15 seconds of life
- clamping cord before onset of ventilation
140
effects of early cord clamping
- lower diastolic BP/mean BP in VLBW infants
- less oxygenation of cerebral regional tissue at 4 and 24 hours
- more likely to have late-onset sepsis
- smaller L ventricular end-diastolic diameters in first 5 days
- decreased Superior Vena Cava (SVC) blood flow in first 48 hours
- leads to low CO syndrome
- significant risk for perinatal brain injury and IVH if umbilical cord clamping preceded fetal lung aeration
141
early cord clamping adverse effects
- variable degree of hypovolemia
- severe hypovolemia when preceded by intrapartum cord compression
- hypoxia
- sudden decrease in preload to the heart
- increases afterload dramatically by obstructing the umbilical arteries --> increases peripheral vascular resistance
- fall in cerebral circulation
- fall in CO
- bradycardia
142
delayed cord clamping effects for a term baby
- improved iron status and other hematological indices over the next 3-6 months
- greater need for phototherapy for jaundice (no well-controlled analysis available)
143
delayed cord clamping effects for a preterm baby
- reduced blood transfusion in immediate postnatal and ensuing weeks
- reduced incidence of IVH (intraventricular hemorrhage)
- increased incidence of jaundice and use of phototherapy, but no reports of increased exchange transfusion
144
ACOG recommends a delay in UCC for ALL healthy infants for ____ after birth (timing)
at least 30-60 seconds
145
WHO recommends placing infant ____ above placenta on maternal abdomen for _____
10 cm above placenta
for 1-3 minutes
146
when is umbilical cord milking recommended?
Umbilical cord milking (UCM) is recommended in the event that the 30-60 delay is too much.
This can be done in three milking motions of the cord in the first 10-15 seconds of life.
147
umbilical cord clamping: preterm considerations (24-37 weeks)
delaying cord clamping by 30-120 seconds resulted in:
- fewer babies needing transfusions for anemia
- better circulatory stability
- reduced risk of IVH (all grades)
- reduced risk of NEC
- reduced risk of late-onset sepsis
148
umbilical cord clamping: very preterm considerations (<30 weeks)
delayed cord clamping by 20-45 seconds resulted in:
- 2-3 fold reduction in IVH
- reduced need for blood transfusions
- greater mean blood pressures in the first hours of life
- no difference in Apgar scores at 5 minutes/body temperature
- just short of statistical significance for halving of mortality with DCC in these infants
149
umbilical cord clamping: term considerations (>37 weeks)
delayed cord clamping for at least one minute resulted in:
- higher early hemoglobin concentration
- increased iron reserves up to 6 months after birth
- no difference in PPH rates
- higher birth weight
- no statistically significant increase in jaundice or polycythemia
150
what is the main purpose of delaying cord clamping?
- to allow more blood flow and oxygenation to come through the umbilical cord from the placenta
NU 330
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