Care of the High-Risk Neonate

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  1. <32 weeks gestation
    Very premature
  2. 32-34 weeks gestation
  3. 34-37 weeks gestation
    late premature
  4. >41 weeks gestation
  5. Maternal Factors affecting birth weight
    • Height
    • Obesity
    • Blood Sugar levels
    • BMI (before preg)
    • Gestational age
    • Pregnancy weight gain
    • Tobacco consumption
  6. Social/Economic risk factors for high-risk neonates
    • Maternal age
    • Low education levels
    • Domestic violence
    • Stress
    • Poverty
    • Smoking
    • Substance abuse
    • Maternal injection
    • Standing long hours
    • Late/no prenatal care
    • Maternal health problems
  7. Baby with weight less than 10th %tile for gestational age
    SGA (small for gestational age)
  8. Small for gestational age is not the same as ______
  9. SGA can be due to ____ (symmetric or asymmetric)
    Intrauterine growth restrictions
  10. Proportional reduction in size of organs except heart and brain...occurs early in pregnancy
    Symmetric IUGR
  11. Disproportional reduction in size of organs...late in pregnancy
    Asymmetric IUGR

    (head looks a lot larger because their brain is normal size, but baby's body is smaller)
  12. Decreased glycogen stores ____ metabolic demand
    increases (hypoglycemia)
  13. Results from birth asphyxia
  14. If baby is stressed in utero, it increases risk for
    meconium aspiration
  15. Characteristics of SYMMETRICAL IUGR
    Equal HC, Length, and Wt

    Appears normally developed for size

    • Thin, long, and wasted
    • Dry loose skin
    • Loss of SQ fat
    • Sparse hair
    • Elderly facial appearanceLarge/overlapping fontanelThin umbilical cord
  16. Characteristics of ASYMMETRICAL IUGR
    HC normal but seems large

    AC decreased due to small liver, spleen, and adrenals

    • Thin, long and wasted
    • ***Dry, loose skin
    • Loss of SQ fat
    • Sparse Hair
    • Elderly facial appearance
    • Large/overlapping fontanel
    • Thin umbilical cord
  17. Baby within or greater than the 90 %ile for gestational age
    LGA (large for gestational age)
  18. Characteristics of LGA babies
    • Macrosomic (weighing >4 - 4.5kg)
    • Large HC and length compared to AGA infant
    • Poor feeding
    • Hypoglycemic (gestational dm)
    • Risk for birth traumas
  19. LGA babies are at risk for _____ and ____ bc there is not a lot of extra room in uterus
    shoulder dystocia and asphyxia
  20. Nursing management for SGA babies
    • ****Assess resp status
    • Maintain normothermic environment (they do not have enough fat reserve so it is difficult for them to maintain body temp)
    • Assess/treat for hypoglycemia/hypocalcemia

    Daily weights

    Early/Frequent feedings
  21. Nursing management for LGA babies
    ***Assess resp status! 

    Assess for birth trauma

    Frequent feedings to decrease chance of low BS

    Assess for polycythemia (they will have too many RBCs)

    Monitor labs: ie bilirubin, hematocrit, and glucose
  22. 2nd leading cause of infant mortality in US
    Prematurity and low birth weight babies
  23. Why are premature babies on the rise
    Older Age
  24. Pre-term Neonatal Assessment Findings:
    Flaccid tone

    Translucent or Transparent skin

    Eyelids may be fused

    Lanugo may be present

    Undescended Testes


    Overriding sutures

    Weak cry

    Absent or diminished reflexes

    Immature suck, swallow and breathing

    Apnea (>20 sec without breath = true apnea)

  25. Respiratory Distress Syndrome is characterized in a Pre-term neonate by
    Underdeveloped alveoli

    Insufficient surfactant

    • Results in Atelectasis -collapse of lung
    • (hypoxemia/hypercarbia = High CO2)
  26. Neonates can develop _____ from being on long term oxygen and becoming dependent
    Bronchopulmonary Dysplasia
  27. Respiratory Assessment of neonate:

    Nasal Flaring


    Retractions (and head bobbing) -- trying hard/ extra work to breath

    Gray/Dusky skin color

    Lethargic -- extra work to breath

    Respiratory acidosis may result
  28. Respiratory interventions of the pre-term neonate
    • Suction nose
    • Positioning
    • Check O2 saturation
    • Give supplemental oxygen (ventilator maybe)
    • Checking blood gases
    • Monitoring Temperature -- if baby gets too cold, it will work harder to warm itself
  29. Breathing with BPD results in difficult delivery of oxygen because it is working against ____
    Stiff Lung Tissue
  30. Ventilator that opens up lungs even more than normal and keeps alveoli open and helps the lungs take a break
  31. Pre-term neonates usually have a central line through _____
    their umbilicus
  32. Retinas are not fully developed before ___ weeks
    28 weeks
  33. Characteristics of retinopathy of prematurity
    • Related to gestational age and weight
    • Occurs in neonates <28 weeks
    • 82% of neonates are <1000g
    • Can result in blindness

    (neonates are not given 100% oxygen in the ventilator because this can cause retinopathy of prematurity)
  34. Risk factors leading to Retinopathy of Prematurity
    Prolonged use of high concentrations of oxygen and mechanical ventilation

    Maternal DM, Smoking, HTN

    Intraventricular Hemorrhage

  35. Nursing interventions for retinopathy in pre-term neonates
    Use of supplemental oxygen to maintain pulse ox parameteres (80s-90s)

    Avoid exposure to bright lights

    Ensure exact oxygen concentration is used
  36. Most common forms of intracranial hemorrhage
  37. Bleeding in the ventricles of the brain in the pre-term neonate
    IVH (intraventricular hemorrhage)
  38. Which grade of IVH: Small amount of bleeding in the floor of the ventricle, not changing in size of ventricles, vascularity in the ventricles are very fragile and can rupture easily
    Grade 1
  39. Which grade of IVH: Bleeding into ventricles, not enough to change size of ventricle
    Grade 2
  40. Which grade of IVH: Bleeding is substantial enough to interfere with normal flow f CSF
    Grade 3
  41. Which grade of IVH: Bleeding into ventricles has resulted in decreased blood supply to other parts of the brain (will be checking ICP)
    Grade 4
  42. Neurological Assessment on a pre-term baby
    Sudden change in condition


    Ox desaturations

    Full fontanel (can tell about hydration status...if it is bulging there may be a brain bleed)


    Apnea (can lead to seizures!!!)




    Diminished activity or LOC

    Increased oxygen demand
  43. Nursing Interventions for Neuro changes/complications
    Assess v/s and neuro status

    Reduce stress and stimulation (only touch them when absolutely needed...we don't want to utilize their energy for anything other than growth)

    Administer volume replacement to decrease hypotension

    Maintain neutral head position: if at risk for IVH, any type of brain injury keep in a good position, any issue with blood flow you do not want to increase any more!
  44. GI disease affecting neonates...inflammation and bowel necrosis (90% in preterm babies)
    Necrotizing Enterocolitis
  45. Causes of Necrotizing Enterocolitis (NEC)
    • Hypotension
    • Stress
    • Hypovolemia
    • Hypoxia
    • Hypothermia
    • Polycythemia (only thing that increases)
  46. Reasons why Pre-term baby could develop NEC
    • GI immaturity
    • Immature host defense mechanisms
    • Aggressive enteral feedings
    • PDA
    • Indomethacin therapy
    • Mucosal injury (hypoxic-ischemic insults)
    • Presence of bacteria within GI lumen
    • Nursery/NICU overcrowding
  47. Reasons why Full-Term neonates could develop NEC
    • Congenital heart disease
    • Hypothyroidism
    • Down Syndrome
    • Small Bowel Atresia
    • Gastrochisis
    • Polycythemia
    • Conditions compromising GI oxygenation/blood flow
    • Exchange transfusion
    • Perinatal "stress"
    • Aggressive enteral feedings
  48. S/S of neonate with NEC
    Apnea, Bradycardia, sometimes Tachycardia


    Temperature instability

    Hypotension, Shock

    GI disturbances (vomiting, bloody stools, abdominal distension, tenderness, increased gastric residual, discoloration)


    Thrombocytopenia and Abnormally high/low WBC cound...can cause septicemia
  49. Many babies with NEC need:
    surgical intervention and go home with G Tubes

    *Check abdominal circumference a lot to make sure there isn't any fluid build up!!!
  50. Nursing Interventions for baby with NEC
    Assess abdominal distention (take air out), vomiting, bloody stools

    Monitor NPO status (gut isn't working) and IV fluids

    Monitor I&O

    Gastric decompression with NG tube

    Prepare for surgery and possible colostomy

    Administer 3 A's: antibiotics, analgesics, antihypertensives
  51. High levels of bilirubin in the blood

    >5 mg/ dl
  52. S/S of hyperbilirubinemia
    • Serum levels >5mg
    • Visible signs of Jaundice
    • Complications may include kernicterus (unconjugated bilirubin in their brain which causes blindness!)
  53. Image Upload 1
  54. Nursing Management of Jaundice
    Assess degree of jaundice

    Obtain bilirubin levels

    Ensure adequate hydration via feeding

    Place under bili lights (phototherapy)

    Assess for s/e of phototherapy

    ***main goal is to flush bilirubin out of their body
  55. S/E of phototherapy
    • Lethargy
    • Eye damage
    • Dehydration
    • Hyperthermia
    • Skin Rash
    • Loose Stools
  56. Baby delivered after completion of 41 weeks
    Post Term Neonate
  57. Risk factors leading to post-term neonates
    Maternal hx of post-term pregnancies

    First pregnancy

    Anencephaly (when brain does not develop, maybe born without brain stem)

    Grand multiparous
  58. Main intervention when suspected meconium aspiration:
    • Suction mouth/nose
    • Admin Ox

    Have NICU and respiratory present
  59. Types of HDN (hemolytic diseases in newborn)
    • Rh Incompatibility 
    • ABO incompatibility
    • Destruction of RBCs in fetus
  60. Management for HDN (hemolytic disease of newborn) is similar to _____
  61. Infection exposure can occur via:
    • Vertical transmission (mother to baby)
    • --tranplacental (syphillis)
    • --ascending (chorioaminiotis)
    • --intrapartal (herpes)

    Horizontal Transmission (nosocomial infections)
  62. Type of transplacental (vertical transmission) infection:
  63. Type of Ascending (vertical transmission) infection:
  64. Type of Intrapartal (vertical transmission) infection:
    Herpes (active lesions)
  65. Example of Horizontal Transmission of infection
    nosocomial infections
  66. Sepsis that occurs within first 7 days of life, usually via vertical transmission
    Early Onset Sepsis

    (life threatening)
  67. Sepsis that occurs after 7 days of life
    Late onset sepsis

    (lower mortality rates)
  68. Sepsis that occurs after 3 months of age (associated with use of indwelling catheters, etc)
    Very late onset sepsis
  69. Nursing Management of sepsis in newborns
    Assess vs for s/s of infection (hypothermia)

    Monitor I&O

    Administer antibiotics as ordered

    Assess respiratory status

    Educate family/visitors on hand

    Monitor laboratory values

    Assist during lumbar puncture

  70. First sign of infection in newborns
  71. Substance abuse (including caffeine) increases risk for:
    prematurity and placental abruption

    • Breathing problems
    • Low Birthweight
    • Feeding Problems
    • Seizures
  72. Withdrawal systems may occur within _____ after birth
    3 hours - 14 days after birth
  73. Withdrawal for alcohol
    3-12 hours
  74. Withdrawal time of narcotics:
    48-72 hours
  75. Withdrawal time of Barbituates:
    1 day - 14 days
  76. Babies experiencing neonatal abstinence syndrome (withdrawal) will be:
    Hyper reflexive
  77. S/S of neonatal withdrawal
    • Apnea
    • Diarrhea
    • Fever
    • High Pitched Cry
    • Irritability
    • Seizures
    • Sweating
    • Yawning
    • Difficulty Sleeping
    • Poor Feeding
    • Inability to console
    • Hypertonia
  78. Abnormal facial features from fetal alcohol syndrome
    • short eye opening
    • short nose
    • flat midface
    • thin upper lip
    • small chin
  79. Nursing interventions for neonate withdrawal
    Assess for s/s withdrawal

    monitor v/s

    Obtain Toxicology

    Daily Weights

    Provide Small/Frequent feedings (higher calorie formula)

    Decrease stimulation-- turn down lights, small frequent feedings


    Provide pacifier (sucking is soothing)
  80. Nursing Dx for the high risk neonate
    • Impaired gas exchange
    • Impaired tissue perfusion
    • Impaired thermoregulation
    • Nutrition less than body requirements (or >)
    • At risk for blood glucose
    • Dysfunction Family
  81. Nursing interventions for High Risk neonates Relating to TEMPERATURE:
    • Minimize cold stress
    • Maintain skin tem 36.1- 36.7 (96.8-97.7)
    • Continuously monitor temp
    • Prevent rapid warming or cooling
    • Use a cap to prevent heat loss from head
  82. Nursing interventions for High Risk neonates Relating to FOOD/FLUIDS:
    Monitor for hypoglycemia

    Assess tolerance of oral or tube feedings

    Monitor hydration closely

    Assess for gastric residual, bowel sounds, change in stool pattern, abdominal girth

    Monitor weight gain or loss
  83. Nursing interventions for High Risk neonates Relating to RESPIRATORY function:
    • Position - semiprone/side lying
    • Maintain resp tract patency
    • Stimulate-- remind to breathe
    • Monitor O2 therapy
    • Assess Resp effort (grunting, nasal flaring, cyanosis, apnea)
  84. Needs of the high risk neonate for Hypothermia treatment/prevention
    Radiant warmers


    Warm blankets, clothes, hats (tell parents to dress babies in one more layer than for adults)

    Kangaroo Care
  85. Needs of the high risk neonate for Cold Stress
    More calories...monitor glucose, temp and oxygen!!!
  86. Needs of the high risk neonate for Oxygen/Ventilation support
    • Nasal Cannula
    • Oxyhood
    • CPAP
    • Ventilator (intubation)...conventional or high frequency (200-900 breaths per minutes to keep lungs expanded all the time)
  87. Needs of the high risk neonate for Nutrition
    • IV nutrition (parenteral) mainly for babies with gut issues
    •  -TPN/Intralipids

    • Enteral Nutrition 
    •  -Trophic feeds (NG tube)
  88. Nursing interventions for baby needing NG tube
    Measure from ear to sternum

    Insert NG tube

    Educate parents on feeding

    Assess daily weights (10-20 gram increase per day)

    Encourage breast feeding or use of breastmilk

    Check gastric residuals prior to/after gavage

    Assess for bowel sounds

    Assess for abdominal distention

    Assess stool for blood

    Encourage sucking (pacifier)-- help them remember the sucking reflex because they don't feed for long periods of time

    Strictly monitor I&O

    Monitor v/s (respirations!) during feeds
  89. Needs of the high risk neonate for Skin
    Assess for breakdown

    Use neutral cleanser (no heavy moisturizer!...only light!)

    Change diapers often

    Frequently change position

    Keep skin moisturized
  90. Needs of the PARENTS of high risk neonates
    Realistically perceiving the infant's medical condition and needs

    Adapting to infant's hospital environment

    Assuming primary caretaking role

    Assuming total responsibility for the infant upon discharge

    Possible coping with the death of the infant if it occurs
  91. Facilitating parental attachment with neonates
    Facilitating family visits

    Allowing the family to hold and touch the baby

    Giving the family a picture of the baby

    Liberal visiting hours

    Encourage the family to get involved in the care (during bath or feeding times)

    Encouraging kangaroo care (mom and dads!)
  92. During parental bonding, you may see what change in baby:
    HR and temp increase
Card Set
Care of the High-Risk Neonate
Care of the High Risk Neonate
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