Chapter 29: High Risk Newborn: Complications Associated with Gestational Age and Development Flashcards Preview

Women's Health Test III > Chapter 29: High Risk Newborn: Complications Associated with Gestational Age and Development > Flashcards

Flashcards in Chapter 29: High Risk Newborn: Complications Associated with Gestational Age and Development Deck (72)
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late preterm infants (LPIs)

  • born between 34 0/7 and 36 6/7 weeks of gestation
  • more stable than preterm infants but are physiologically and metabolically immature and have higher morbidity and mortality than full term infants
  • at risk for: hypothermia, respiratory problems, hypoglycemia, hyperbilirubinemia, feeding difficulties, sepsis, long term neurodevelopmental disorders


what are contributing factors to late preterm birth?

  • elective and medically induced inductions and cesarean births
  • preterm labor
  • pROM
  • preeclampsia
  • multifetal pregnancies
  • obesity
  • assisted reproductive technology
  • advanced maternal age
  • inaccurate estimate of gestational age before delivery


thermoregulation with LPIs

  • may develop cold stress that is not noticed until signs appear or until a vital signs check (which often occur only once a shift)
    • therefore, nurses should check V/S, esp temp, Q3-4 hours for first 24 hours and then every shift
  • kangaroo care: often used to keep infants warm
    • it is a method of skin to skin b/w infants and parents


feedings with LPIs

  • may have immature suck and swallow reflexes, shorter awake periods, and may fall asleep during feedings before being fed enough
  • may have difficulty with latch
  • have an inc caloric need and should be fed every 2-3 hours
  • football and cross cradle holds are helpful to use to help infants feed
  • monitor blood glucose at least 2x daily b/c infant at risk for hypoglycemia
  • must monitor and document breastfeeding evaluations at least 2x daily


discharge of LPIs

  • should not be discharged earlier than 48 hours after bith
  • infants should be feeding adequately and have normal V/S for at least 24 hours before discharge
  • bilirubin levels should be checked
  • teach parents to keep infant warm
  • car seat challenge: ensure the infant can sit in car seat w/o bradycardia, apnea, or O2 desats
    • should be monitored for at least 30 min
  • teach parents signs of complications such as jaundice/dehydration
  • f/u w/in 24-72 hours


what is defined as preterm infant?

what are the 3 categories of prematurity?

  • preterm: any infant born before beginning of 38 weeks of gestation
    • late preterm: 34-37 weeks
    • moderate preterm: 32-34 weeks
    • very preterm: <32 weeks


moderate preterm

  • born between 32-34 weeks
  • higher risk than late preterm infants for hypothermia, respiratory problems, hypoglycemia, hyperbilirubinemia, feeding difficulties, sepsis, and long term neurodevelopmental disorders
  • do not have suck, swallow, breath coordination


early/very preterm

  • less than 32 weeks gestation
  • 24 weeks is point of viability
  • 500 grams is indicator of initial survival


low birth weight

  • low birth weight most often caused by prematurity
    • LBW: any infant weighing 5 lb 8 oz (2500 g) or less at birth and of any gestational age
    • very low birth weight (VLBW): infants weighing less than 3 lb 5 oz (1500 g) or less at birth
    • extremely low birth weight (ELBW): infants weighing less than 2 lb 3 oz (1000 g) at birth
  • leads to major complications
  • often the cause of: preterm labor, chronic health conditions (DM), infection, placental problems, not gaining weight during pregnancy, hx of LBW infants, cigarette/alcohol abuse


appearance of preterm infants

  • frail and weak
  • less developed flexor muscles and muscle tone
  • limp extremities with no resistance
    • often lie in extended position
  • lack subQ tissue or white fat which makes thin skin appear red and translucent
  • vernix and lanugo are abundant
  • plantar creases are absent if less than 32 weeks
  • pinnae of ears are soft, flat, and contain little cartilage
    • they lack the rolled over appearance
  • female: clitoris and labia minora are large and not covered by labia majora
  • male: undescended testes, with smooth scrotal sac


behavior of preterm infants

  • depends on gestational age
  • may have poor development of flexion and little excess energy for maintaining muscle tone
  • easily exhausted by noise and activity
  • may respond with low O2 levels and stress related behavior
  • cry may be feeble


problems with respiration in preterm infants

  • immature lungs
    • presence of surfactant in adequate amounts is of primary importance b/c it allows the work of breathing to be lowered
      • if lack of surfactant-->RDS
    • ppor cough reflex and narrowed respiratory passageways


assessment of preterm respiratory system

  • periodic vs apneic breathing
    • periodic: cessation of breathing for 5-10 sec w/o other changes followed by 10-15 sec of rapid respirations
      • no changes in color or HR
      • normal
    • apneic: absence of breathing lasting more than 20 sec
      • accompanied by cyanosis, pallor, bradycardia, hypotonia
      • may require tactile stimulation and ventilation
  • should assess for WOB and location and severity of retractions
  • grunting is an early sign of RDS


respiratory nursing care of preterm infants: equipment

  • respiratory equipment
    • O2 hood: if infant can breathe independently but need extra O2
    • NC: can be used if infant breathes well independently
      • can be used for home O2
      • should be warmed and humidified
    • CPAP: used to keep alveoli open and improve lung expansion
    • ventilation: when respiratory failure, severe apnea, bradycardia
      • can use high frequency ventilation to provide fast respirations w/ less pressure and volume


respiratory nursing care of preterm infants: Positioning

  • side or prone positions used to help with drainage of secretions
    • not recommended in normal infants b/c of SIDS risk
    • in preterm, prone position helps inc oxygenation, enhance respiratory control, improve lung mechanics and volume, and reduces energy expenditure
  • start supine sleeping as soon as infant can tolerate
    • can often be used at approx 32 weeks


respiratory nursing care of preterm infants: suctioning and maintaining hydration

  • suction mouth then nose
    • only suction as necessary
    • each suction attempt should only be 5-10 seconds long and inc O2 should be provided before and after each attempt
  • adequate hydration is important to keep secretions thin so they can be removed by drainage or suction


problems with thermoregulation in preterm infants

  • skin is thin, blood vessels near surface, and little subQ fat so heat loss is rapid
    • preterm so less brown fat was allowed to accumulate
  • also they are in extension rather than flexion, so allow more heat loss
  • temp control center of the brain is immature
  • complications of heat loss: hypoglycemia, respiratory problems, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production


assessment of thermoregulation in preterm infants

  • temp should be recorded Q30-60 min until stable, then Q1-3 hours
  • axillary temp should be between 36.3 deg C and 36.9 deg C
  • low temp may be early sign of infection
  • hypoglycemia and respiratory distress may be first sign of temp instability


signs of inadequate thermoregulation in preterm infants

  • axillary temp <36.3 deg C or >36.9 deg C
  • abdominal skin temp <36 deg C or >36.5 deg C
  • poor feeding or feeding intolerance
  • irritability followed by lethargy
  • weak cry or suck
  • dec muscle tone
  • cool skin temp
  • mottled, pale, or acrocyanotic skin
  • signs of hypoglycemia
  • signs of respiratory difficulty


nursing care to maintain a neutral thermal environment

  • neutral thermal env prevents the need for inc O2 to maintain the infant's body temp
  • delivery room should be warm to dec heat loss at birth
    • immediately dry baby (and keep dry) and place on mother or in warmer
    • if less than 29 weeks: wrap in polyethylene bag to prevent evaporative heat loss
  • can use open radiant warmers, but be sure to prevent heat loss through convection from drafts
  • warmed and humidified O2, b/c thermal receptors in face are very sensitive
  • can use heated blankets and hats 
  • warm formula, breastmilk


nursing care to wean an infant to an open crib

  • prep for this early
    • should keep an infant dressed as much as possible even if in incubator to help infant get used to different temp on face than rest of body
  • can begin gradual weaning from external heat if:
    • weight about 3 lb 5 oz (1500 g)
    • consistent weight for 5 days
    • no medical complications
    • tolerating feedings
  • when move to crib, should double wrap infant to insulate body heat


problems with fluid and electrolyte imbalance in preterm infants

  • preterm infants lose fluid easliy and loss inc with degree of prematurity
    • rapid RR and use of O2 inc fluid loss from lungs
    • thin skin and lack of flexion inc water loss
    • heat from radiant warmers/incubators leads to water loss
  • ability of kidneys to conc or dilute urine is poor, so fragile balance between dehydration and overhydration
    • normal urinary output: 1-3 mL/kg/hour during first few days
    • after 24 hours: output less than 0.5 mL/kg/hour is considered oliguria


assessment of fluid and electrolyte balance in preterm infants

  • be on high alert for fluid overload or deficit
  • monitor I/O, strictly
  • weigh diapers to determine output (1 g=1 mL)
    • check specific gravity to determine if dilute or concentrated urine (should be b/w 1.002-1.010)
  • daily weights of infant to determine fluid loss or gain
  • monitor for signs of dehydration and overhydraiton


signs of dehydration in the newborn

  • urine output <1 mL/kg/hour
  • urine SG >1.010
  • weight loss greater than expected
  • dry skin and mucous membranes
  • sunken anterior fontanel
  • poor tissue turgor
  • blood: elevated Na, protein, HCT
  • hypotension


signs of overhydration in the newborn

  • urine output >3 mL/kg/hour
  • urine SG <1.002
  • edema
  • weight gain greater than expected
  • bulging fontanels
  • blood: dec Na, protein, HCT
  • moist breath sounds
  • difficulty breathing


nursing interventions for fluid and electrolyte balance in preterm infants

  • regulate IV fluids with a prevision of 0.1 mL/hour
  • IV meds diluted in as little fluid as possible
  • hourly check of IV site for infiltration
  • strict I&O with SG checks
  • weigh infants daily


skin problems in preterm infants

  • skin is fragile, permeable, and easliy damaged
    • do not use standard adhesive tape on their skin
    • disinfectants can injure their skin
  • assess skin regularly
  • nursing interventions:
    • avoid adhesives, alcohol, or betadine
    • remove adhesive slowly
    • chlorhexidine gluconate is a common disinfectant that can be used
    • pH balanced cleanser (w/ pH from 5.5-7) should be used for bath (preterm infants should not be bathed every day)
    • humidity in incubators to reduce drying of skin
    • use emollients on skin to help reduce skin fissures
    • frequent position changes to reduce skin breakdown


infection in preterm infants

  • high rate of infection due to exposure to maternal infection, lack of IgG transfer from mother, immature immune system
    • prolonged hospital stays and invasive procedures also inc the risk
  • be alert for signs of sepsis
  • nursing interventions:
    • hand washing
    • no jewelry
    • limit exposure to family and staff who have contagious illnesses
    • strict sterile technique for central lines/dressing changes


pain assessment in preterm infants

  • pain assessed whenever V/S assessed with NIPS or Premature Infant Pain Profile (PIPP)
    • these assess gestational age and behavior states, HR, O2 sats, brow bulge, eye squeeze, and nasolabial furrow
  • common signs of pain:
    • inc/dec HR and RR
    • inc BP
    • dec O2 sats
    • color changes: red, dusky, pale
    • high pitched, intense, harsh cry
    • whimpering, moaning
    • eyes squeezed shut
    • mouth open grimacing
    • furrowing or bulging of brow
    • tense, rigid muscles or flaccid muscle tone
    • rigidity or flailing of extremities
    • sleep wake pattern changes


nursing interventions for pain in preterm infants

  • prepare infants for painful precedures by waking them slowly and gently and using containment 
    • (simulates the enclosed space of the uterus and prevents excessive and disorganized motor activity-->keep extremities flexed w/ swaddling or w/ hands, position in supine or side lying w/ at least 1 of the infant's hands near the mouth for sucking)
  • kangaroo care and breastfeeding can help reduce pain
  • nonnutritive sucking on a pacifier
    • put sucrose in infant's mouth 2-3 min before procedure with pacifier
  • opioids and acetaminophen