nurs 137 - thehighriskneonate
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NURS 137 - TheHighRiskNeonateTRANSCRIPT
M E R E D I T HW I L L I A M S ,R N , B S N
The High Risk Neonate
Objectives
By the end of this class, students will be able to: Identify the factors at birth that indicate an at risk
newborn Define the specific characteristics of SGA, AGA,
and LGA infants Discuss the potential complications and risk factors of
the high risk neonate Compare the physical assessment characteristics of
the premature infant to a full term infant and a post term infant
Discuss the nursing interventions related to the care and management of the high risk infant in
the clinical setting
At Risk Newborns
Factors that influence birth outcomes: Birth weight Gestational age Type and length of newborn illness Environmental factors Maternal factors Maternal-infant separation
At Risk Newborns
Identifying a newborn at risk: Low socioeconomic status
Limited or no prenatal care Preexisting maternal conditions
heart diseaseDMHTNHypothyroidrenal disease
Exposure to environmental factorstoxic chemicalsillicit drugs
At Risk Newborns
Maternal Factorsageparity
Pregnancy complicationsplacenta abruptionplacenta previaoligohydramniospreterm laborpremature rupture of membranespre-eclampsiauterine rupture
At Risk Newborns
Why identify at risk neonates? Monitor pregnancy closely Start treatment as needed Arrange to deliver in appropriate facility with the
resources for mother and baby
Newborn Classifications
Preterm: < 37 weeks
Late Preterm: 34 to 36 6/7 weeks
Term: 38 to 41 weeks
Postterm: > 42 weeks
Updated Classifications
Preterm:
Extremely Preterm: < 28 weeks
Very Preterm: 28 0/7 to 32 weeks
Late Preterm: 32 0/7 to 36 6/7 weeks
Updated Classifications
Term/Postterm:
Early term: 37 0/7 to 38 6/7 weeks
Full term: 39 0/7 to 40 6/7 weeks
Late term: 41 0/7 to 41 6/7 weeks
Postterm: 42 0/7 weeks and beyond
Growth Chart
Infant Classifications
SGA Infants that fall below the 10th percentile
AGA Infants that are > 10th percentile, but < 90th percentile
LGA Infants that fall above the 90th percentile
Infant Classifications
Let’s practice! 37 5/7 weeks gestation, weighing 2954g
39 0/7 weeks gestation, weighing 3855g
40 1/7 weeks gestation, weighing 2590g
Small for Gestational Age
Less than 10th percentile for birth weight May be preterm, term, or postterm Under grown infants – IUGR Commonly seen in mothers who smoke or
have high blood pressure Increased incidence of
polycythemia and hypoglycemia
Small for Gestational Age
Intrauterine growth restriction Maternal factors Maternal disease Environmental factors Placental factors Fetal factors
Complications of SGA
Fetal hypoxia Aspiration syndrome Hypothermia Hypoglycemia Polycythemia Congenital malformations
Nursing Management for SGA
Monitor for signs of respiratory distress Monitor temperature > 36.4 ◦C Monitor blood glucose > 45 mg/dl Assess feeding Support increased caloric needs Support breastfeeding and milk production
Large for Gestational Age
Greater than the 90th percentile for birth weight
Often associated with maternal diabetes Genetic predisposition – large parents, large
infants Multiparous women – 2-3 times more
likely than primiparous women Male – usually larger than females Infants with certain anomalies tend to be LGA
Complications of LGA
Birth trauma due to CPD
Increased incidence of C/S & oxytocin-induced birth
Hypoglycemia, polycythemia, & hyperviscosity
Nursing Management of LGA
Monitor vital signs Screening for hypoglycemia and polycythemia Observing for signs and symptoms of birth
trauma Assess feeding Support breastfeeding and milk production
Nursing Management of LGA
Infants of Diabetic Mothers Close monitoring in first hours of life Hypoglycemia - <45 mg/dl Hypocalcemia - <7 mg/dl Hyperbilirubinemia – seen at 48-72 hrs, hepatic
immaturity and/or birth trauma Birth Trauma – shoulder dystocia, brachial plexus
injuries, subdural hemorrhage, cephalhematoma, and asphyxia
Nursing Management of LGA
Infants of Diabetic Mothers cont… Polycythemia – hyperglycemia/hyperinsulinism -
increased O2 comsumption – fetal hypoxia – increased erythropoietin production – increased Hct – potential hyperbilirubinemia
Respiratory Distress Syndrome (RDS) – less mature lungs for gestational age
Congenital malformations – high risk with poor glycemic control especially during first trimester
Nursing Management of the Late Preterm
At risk for: Dehydration Hypoglycemia Hyperbilirubinemia Hypothermia Sepsis Respiratory instability Failure to thrive
Nursing Management of the Late Preterm
Careful Monitoring Encourage skin to skin Encourage breastfeeding on demand Initiate supplementation – expressed
breast milk (EBM) or formula if:Birth weight < 2500 g< 36 weeks gestationPoor reserve – temp instability or hypoglycemiaPoor feeding – poor latch or < 10 min at breastWeight loss > 3% per day or > 8% total
Nursing Management of the Late Preterm
Feeding every 8-12 times/day – not > 3 hrs between feeds
Encourage increased milk production – breast pump or hand expression after feeds
Increased caloric intake – 5-10 ml/feed in first 24 hrs of life; 10-30 ml/feed in 24-96 hrs of life with MD order
Use SNS or syringe feeding for supplementationLactation Consult – documented feeding
plan for discharge
Follow up – 1-2 days of discharge
Physical Assessment of the Newborn
What are some characteristics of the normal newborn?
What does a newborn look like?
Physical Assessment
What does a preterm infant look like?
Physical Assessment
Preterm infant Increased lanugo Increased vernix Skin – thin, translucent Less defined
creases in hands and feet
Relaxed tone Decreased body fat
Physical Assessment
What does a postterm infant look like?
Physical Assessment
Postterm infant Dry, cracking skin Decreased vernix Decreased lanugo Long fingernails Increased scalp hair Wasted
appearance – decreased fat storage
Meconium staining – skin, nails, umbilical cord
Well-defined creases in hands
and feet
Ballard Exam
Case Study
As a nursing student, you are working in labor and delivery and are assigned a mother/baby couplet for your shift. The mother is 19 years old, G1P1, blood type O+,GBS positive. She received 3 doses of ampicillin during her labor. Her pregnancy was complicated by gestational diabetes. Her blood glucose was well controlled by diet alone. She has no allergies and no significant health problems prior to pregnancy. At the start of your shift, the infant is approximately 6 hours old.According to the H&P, the infant was delivered at 36 4/7 weeks gestation. The birth weight is 2210 g. The infant returned to the mother from the NICU after a 4 hour observation for mild respiratory distress. Upon entering the room, you observe that the infant is swaddled loosely in a blanket and lying on the bed next to the mother.
What risk factors do you note when caring for this couplet? What vital signs are going to be especially important when caring for this
infant? What physical characteristics do you expect to see when you examine this
infant? What special feeding issues will you need to assess on this infant?
Develop a feeding plan that would be appropriate considering the
infant’s gestational age and weight. How will you approach this mother when teaching her about
infant care, considering that she is a teen mother?
References
Davidson, M., London, M., & Ladewig, P. (2012). The newborn at risk: Conditions present at birth, Olds’ maternal-newborn nursing & women’s health across the lifespan (pp. 889-937). Boston: Pearson
The American College of Obstetrics and Gynecologists. (2013). Definition of term pregnancy. Retrieved from http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice/Definition_of_Term_Pregnancy
UC Davis Health System. (2014). Policies & Procedures: Late pre term/early term protocol (34 0/7 to 37 6/7 weeks gestation). Retrieved from http://intranet.ucdmc.ucdavis.edu/policies/patient_care_standards/obste trics/XVI-50.shtml
World Health Organization. (2013). Preterm birth. Retrieved from
http://www.who.int/mediacentre/factsheets/fs363/en/