Module 5 High Risk Newborn

What is the definition of a preterm infant?

An infant born prior to 37 weeks gestation.

What is a key skin feature of a preterm infant's hand?

Few palmar creases.

What are three head/facial features of a preterm infant?

• Soft, pliable ear cartilage

• Matted hair

• Fused eyelids

What is the typical posture and muscle tone of a preterm infant?

Lax posture with poor muscle tone.

What does the breast and nipple area look like in a preterm infant?

Barely visible breast and nipple area.

What is the typical weight of a preterm infant?

Less than 5.5 lbs (2,500 grams).

What is the general appearance of a preterm infant?

Scrawny with poor muscle tone and minimal subcutaneous fat.

What genital findings may be present in a preterm male infant?

Undescended testes and minimal scrotal rugae.

What genital findings may be present in a preterm female infant?

Prominent labia and clitoris.

What skin and hair features are common in a preterm infant?

• Thin, transparent skin

• Plentiful lanugo

• Abundant vernix

• Matted scalp hair

What are some head and eye findings in a preterm infant?

• Soft, spongy skull bones

• Poorly formed ear pinna

• Fused eyelids

What findings are seen in the hands and feet of a preterm infant?

Absent to few creases in soles and palms.

What are four common causes (etiologies) of preterm birth?

• Infections or inflammation

• Maternal or fetal distress

• Bleeding

• Stretching of the uterus (not listed, but often included)

Why does preterm birth put the infant at risk?

Because the infant’s body systems are immature and not fully developed.

What are five common problems preterm infants face?

• Hypothermia

• Hypoglycemia

• Hyperbilirubinemia

• Immature body system functions

• Respiratory distress syndrome (RDS)

What causes respiratory distress syndrome (RDS) in preterm infants?

Immature lungs and lack of surfactant, which makes breathing difficult.

Why are preterm infants at risk for hypothermia?

Due to thin skin, minimal fat, and poor temperature regulation.

Why are preterm infants at risk for hypoglycemia?

Due to limited glycogen stores and immature liver function.

Why are preterm infants at risk for hyperbilirubinemia?

Because of immature liver and increased breakdown of red blood cells.

What defines a post-term infant?

An infant delivered after 42 weeks gestation.

What are common skin characteristics of a post-term infant?

• Dry, cracked, wrinkled skin

• Possibly meconium-stained

What are typical body features of a post-term infant?

• Long, thin extremities

• Long nails

• Creases covering the entire soles of feet

What are common head and hair features in a post-term infant?

• Wide-eyed, alert expression

• Abundant scalp hair

What are signs of decreased fetal nutrition in post-term infants?

• Thin umbilical cord

• Limited vernix and lanugo

What are three common problems associated with post-term infants?

1. Hypoglycemia

2. Hypothermia

3. Polycythemia

Why are post-term infants at risk for hypoglycemia?

Due to depleted glycogen stores after prolonged gestation.

Why are post-term infants at risk for hypothermia?

Because of reduced subcutaneous fat and temperature regulation issues.

Why are post-term infants at risk for polycythemia?

Due to chronic hypoxia in utero, which stimulates excess red blood cell production.

What defines an SGA infant?

An infant whose weight is below the 10th percentile for gestational age.

What are two major causes of SGA?

• <28 weeks gestation: Overall growth restriction (infant may never catch up)

• >28 weeks gestation: Intrauterine malnutrition (normal growth possible with proper postnatal nutrition)

What are the physical characteristics of an SGA infant?

• Head disproportionately large

• Wasted appearance of extremities

• Loose, dry skin

• Reduced subcutaneous fat

• Decreased breast tissue

• Scaphoid abdomen (sunken)

• Wide skull sutures

• Poor muscle tone (especially buttocks/cheeks)

• Thin umbilical cord

Why might an SGA infant have a scaphoid abdomen?

Due to lack of subcutaneous fat and muscle tone.

What complications are SGA infants at risk for?

• Perinatal asphyxia

• Difficulty with thermoregulation

• Hypoglycemia

• Polycythemia

• Meconium aspiration

• Hyperbilirubinemia

• Birth trauma

Why are SGA infants at risk for hypoglycemia?

They have limited glycogen and fat stores, which makes it harder to maintain blood sugar levels.

Why are SGA infants at risk for thermoregulation issues?

Because of reduced subcutaneous fat and wasted muscle tone.

What causes polycythemia in SGA infants?

Chronic intrauterine hypoxia, which leads to increased red blood cell production.

What defines a Large for Gestational Age (LGA) infant?

An infant with a birth weight above the 90th percentile or over 8.8 lbs (4,000 g).

What are physical characteristics of an LGA infant?

• Plump body

• Excessive fat deposits

• Hypotonic (low tone) muscles

• Possible bruising or fractures due to birth trauma

What are common maternal factors causing LGA infants?

• Maternal diabetes

• Maternal obesity

• Multiparity

• History of macrosomic infant

• Post-term pregnancy

What complications are LGA infants at risk for?

• Birth trauma (due to size)

• Hypoglycemia (due to hyperinsulinemia)

• Respiratory distress (especially with C-section)

• Polycythemia

• Hyperbilirubinemia

Why are LGA infants at risk for hypoglycemia?

Due to increased insulin production in response to maternal hyperglycemia.

Why might LGA infants delivered by C-section experience respiratory distress?

Lack of thoracic squeeze, which helps clear fetal lung fluid during vaginal birth.

What is the normal blood glucose level for a newborn within the first 24 hours?

40–60 mg/dL

What is the normal blood glucose level for a newborn after the first 24 hours?

50–90 mg/dL

What are signs and symptoms of hypoglycemia in a newborn?

• Jitteriness or tremors

• Poor feeding

• Lethargy

• Hypothermia

• Flaccid muscle tone

• Irregular respirations

What is the initial method for checking blood glucose in a newborn?

Heel stick on the outer portion of the heel

What are typical treatments for newborn hypoglycemia?

• Frequent breastfeeding every 2 hours

• IV glucose if hypoglycemia is severe or symptomatic

What problems are associated with infants of diabetic mothers?

• Macrosomia (due to excess glucose, leading to excessive insulin production)

• Hypoglycemia (due to high insulin levels at birth)

• Respiratory distress syndrome (due to delayed lung maturation)

• Congenital anomalies (e.g., heart defects, neural tube defects)

Why are infants of diabetic mothers at risk for macrosomia?

Excess glucose crosses the placenta, causing the fetus to produce excess insulin, which promotes growth.

Why are infants of diabetic mothers at risk for hypoglycemia at birth?

At birth, the infant’s high insulin levels persist, but the glucose supply from the placenta is cut off, leading to low blood sugar.

Why do infants of diabetic mothers experience respiratory distress syndrome?

Delayed lung maturation occurs due to insulin's inhibitory effect on surfactant production in the fetal lungs.

What types of congenital anomalies are more common in infants of diabetic mothers?

• Heart defects

• Neural tube defects (e.g., spina bifida, anencephaly)

What are normal bilirubin levels in a newborn and when are levels concerning?

• Normal bilirubin: < 5 mg/dL

• Concerning bilirubin: 12-25 mg/dL

What causes hyperbilirubinemia in newborns?

• Immature liver that cannot break down RBCs efficiently

• Physiologic jaundice

• Pathologic jaundice

• Blood type incompatibility (e.g., ABO or Rh incompatibility)

• Inadequate feeding leading to dehydration or poor elimination

What is hyperbilirubinemia in newborns?

Excess bilirubin in the blood causes yellowing of the skin and mucous membranes, often due to an immature liver.

What is the treatment for hyperbilirubinemia in newborns?

• Phototherapy (exposure to special light to break down bilirubin)

• Frequent breastfeeding (to promote hydration and elimination)

• Exchange transfusion (in severe cases, to replace the infant’s blood with fresh donor blood)

What are the key risk factors for hyperbilirubinemia in newborns?

• Prematurity

• Inadequate feeding (leading to dehydration or low elimination)

• Blood type incompatibility (e.g., Rh or ABO incompatibility)

• Bruising during birth (increases RBC breakdown)

• Sibling with jaundice

• Maternal diabetes

What is a key sign of hyperbilirubinemia?

aundice (yellowing of the skin and mucous membranes, especially the face and chest)

What are the nursing interventions for newborns with hyperbilirubinemia?

• Assess for jaundice and document its progression.

• Monitor bilirubin levels regularly (total serum bilirubin).

• Promote frequent breastfeeding (every 2-3 hours) to help eliminate bilirubin through stool.

• Administer phototherapy as ordered and monitor for side effects (e.g., eye protection, skin care).

• Ensure adequate hydration and monitor urine output.

• Educate parents on the importance of feeding and phototherapy care.

How can a nurse assess for Rh incompatibility?

• Assess maternal history (Rh-negative mother, Rh-positive baby).

• Look for signs of jaundice and anemia in the newborn.

• Check for hemolysis or signs of increased breakdown of RBCs.

What are the nursing interventions for reducing bilirubin levels in a newborn with hyperbilirubinemia?

• Early feeding (to promote elimination of bilirubin through stool)

• Phototherapy (using light to break down excess bilirubin)

• Exchange transfusions (in severe cases, to replace the infant’s blood with fresh donor blood)

How can nurses provide education and support for parents of a newborn with hyperbilirubinemia?

• Explain the condition (jaundice, causes, and treatment options like phototherapy)

• Discuss the importance of frequent feeding (to support bilirubin elimination)

• Demonstrate proper phototherapy care (e.g., eye protection, monitoring temperature, ensuring infant is well-hydrated)

• Offer emotional support for concerns about the baby’s health and treatment.

What is home phototherapy, and how should it be managed?

• Home phototherapy allows parents to manage phototherapy at home.

• Monitor bilirubin levels as prescribed, ensuring they do not exceed safe levels.

• Ensure proper skin exposure to the phototherapy light and maintain eye protection for the baby.

• Ensure adequate hydration and continue frequent breastfeeding.

What is polycythemia in newborns?

Polycythemia is a condition in which there is an abnormally high concentration of red blood cells in the blood, leading to increased blood viscosity.

Which newborns are at risk for polycythemia and why?

• SGA (Small for Gestational Age): Reduced placental blood flow increases fetal erythropoiesis (production of red blood cells).

• Post-term infants: Prolonged gestation can lead to increased red blood cell production.

• Infants of diabetic mothers: Elevated blood glucose levels can lead to increased fetal erythropoiesis.

What complications or problems are associated with polycythemia in newborns?

• Increased blood viscosity can lead to poor blood flow, causing organ damage (e.g., brain, kidneys).

• Respiratory distress, poor feeding, and jaundice may occur as a result of increased blood thickness and the breakdown of excess red blood cells.

What can polycythemia lead to in newborns?

• Poor circulation and blood clots (due to increased blood viscosity)

• Hypoglycemia (because of increased utilization of glucose by red blood cells)

• Jaundice (due to the breakdown of excess red blood cells, releasing bilirubin)

• Respiratory distress (increased blood viscosity can impair oxygen delivery)

• Neurological issues (due to poor blood flow and oxygenation to the brain)

How does polycythemia lead to poor circulation and blood clots?

Increased red blood cell mass makes the blood thicker, which can reduce the flow of oxygen and nutrients to organs and increase the risk of blood clots.

How does polycythemia contribute to jaundice in newborns?

The excessive breakdown of red blood cells increases bilirubin production, which can overwhelm the liver’s ability to process and eliminate it, leading to jaundice.

What is Respiratory Distress Syndrome (RDS) in newborns?

RDS occurs as a result of surfactant deficiency in the lungs, characterized by poor gas exchange and ventilatory failure due to lung immaturity and the lack of sufficient alveolar surfactant.

What is the role of surfactant in the lungs?

Surfactant is a phospholipid that helps the alveoli expand and prevents their collapse. It is crucial for proper gas exchange as it reduces surface tension in the lungs, enabling efficient oxygen and carbon dioxide exchange.

What causes RDS in newborns?

RDS is primarily caused by lung immaturity and a deficiency of surfactant, which is usually produced at higher levels closer to full term. Preterm infants are particularly at risk due to the insufficient amount of surfactant in their lungs.

How does a deficiency of surfactant lead to respiratory distress?

Without enough surfactant, the alveoli are prone to collapse, which impairs gas exchange, causing low oxygen levels and high carbon dioxide levels. This results in respiratory failure.

What is a risk factor for RDS related to gestation period?

Preterm gestation is a risk factor for RDS because immature lungs cannot produce enough surfactant needed for proper gas exchange.

Why does maternal diabetes mellitus increase the risk for RDS in newborns?

Maternal diabetes mellitus can result in high glucose levels, which disrupt surfactant production in the fetus, increasing the risk of RDS.

How does a C-section without labor contribute to the development of RDS in newborns?

A C-section without labor can limit the natural release of stress hormones that help the fetus produce surfactant, increasing the risk for RDS.

Why is perinatal asphyxia a risk factor for RDS?

Perinatal asphyxia from conditions like meconium staining, cord prolapse, or nuchal cord can reduce oxygen to the fetus, impairing lung development and increasing the risk of RDS.

How does maternal hypotension affect the risk of RDS?

Maternal hypotension reduces blood flow to the placenta, which can impair the oxygen and nutrient supply to the fetus, leading to immature lung development and a higher risk of RDS.

What role do barbiturates or narcotics taken by the mother close to delivery play in the development of RDS?

The use of barbiturates or narcotics near delivery can depress fetal respiratory drive and affect surfactant production, increasing the risk of RDS.

Why does pre-labor rupture of membranes increase the risk of RDS?

Pre-labor rupture of membranes can lead to infection and affect the maturation of fetal lungs, increasing the likelihood of RDS.

What effect does maternal bleeding during the third trimester have on the fetus and its risk of RDS?

Maternal bleeding reduces oxygen supply to the fetus, which can impair lung development and increase the risk of RDS.

How does hypovolemia in the mother affect the fetus’s risk of RDS?

Hypovolemia (low blood volume) in the mother reduces placental perfusion, leading to poor oxygen supply for fetal lung development, raising the risk for RDS.

Which genetic factor is a risk for developing RDS?

White males are genetically at a higher risk for developing RDS compared to other groups.

How does hydrops fetalis increase the risk of RDS?

Hydrops fetalis involves massive fetal edema caused by hyperbilirubinemia, which impairs lung development and increases the risk of RDS.

What are some respiratory signs of RDS in a newborn?

• Expiratory grunting

• Nasal flaring

• Chest wall retractions

• See-saw respirations

• Generalized cyanosis

What heart rate range is commonly seen in a newborn with RDS?

A heart rate >150 to 180 beats per minute is commonly observed in newborns with RDS.

What lung sounds might be heard on auscultation in a newborn with RDS?

Fine inspiratory crackles are typically heard in newborns with RDS.

What is the typical respiratory rate in a newborn with RDS?

Tachypnea with a respiratory rate >60 breaths per minute is a common finding in RDS

What is the Silverman-Anderson Index, and what score indicates severe respiratory distress?

The Silverman-Anderson Index is a scoring system for assessing respiratory distress. A score >7 indicates severe respiratory distress.

What would a chest x-ray of a newborn with RDS show?

The chest x-ray would show hypoaeration, underexpansion, and a ground glass pattern.

What type of care is essential for a newborn with RDS?

Supportive care and close monitoring are essential to manage a newborn with RDS.

What respiratory modalities are commonly used in managing RDS?

• Ventilation (CPAP, PEEP)

• Exogenous surfactant

• Oxygen therapy

What is the role of antibiotics in the management of RDS?

Antibiotics are administered if there are positive cultures indicating infection.

How is metabolic acidosis managed in a newborn with RDS?

Correction of metabolic acidosis is part of the management, usually through appropriate medications and interventions.

What fluid management strategies are used for RDS?

• Fluids are provided to maintain hydration.

• Vasopressors may be used to support blood pressure.

What are the feeding strategies for a newborn with RDS?

Gavage feedings or IV feedings are used, depending on the baby’s condition and ability to tolerate feedings.

Why is blood glucose monitoring important for a newborn with RDS?

Monitoring blood glucose levels is critical because newborns with RDS can be at risk for hypoglycemia.

What nursing technique is recommended to minimize stress and improve oxygenation for an RDS infant?

Clustering of care and placing the baby in a prone or side-lying position to optimize oxygenation.

How can parents be supported when caring for a newborn with RDS?

Providing parental support and education is crucial for managing the stress and understanding the infant's condition.

What are the causes of early onset sepsis in a newborn?

Early onset sepsis (within 72 hours of life) is typically caused by maternal transmission of infections.