The Newborn at Risk: Gestational and Acquired Disorders Chapter 20

1. The Newborn at Risk: Gestational and Acquired DisordersChapter 20

2. OBJECTIVES • Define the classifications used to describe newborns based on their size, gestational age, or weight. • Explain the various components of the gestational age assessment. • Describe the most common underlying condition that causes a newborn to be SGA, and explain the reason this condition occurs. • Differentiate between symmetric and asymmetric growth restriction in SGA infants. • List factors that contribute to a newborn being LGA. • List possible contributing factors for preterm birth. • Compare characteristics of the preterm newborn with those of the term newborn. • Identify complications commonly associated with preterm newborns. • Describe the goals of care for the preterm newborn. • Describe major aspects of nursing care for the postterm newborn. • Give details of care for three acquired respiratory disorders associated with newborns. • Describe hemolytic disease of the newborn. • Explain important features of treatment, clinical manifestations, and nursing considerations for the newborn of a diabetic mother. • Discuss the clinical manifestations of and nursing care for a newborn of a chemically dependent mother. • Differentiate causes of and care for newborns with congenitally acquired infections.

3. The Newborn at Risk: Gestational and Acquired Disorders • 10% of infants are born ill or develop health problems shortly after birth • Fragile newborns need specialized care in the neonatal intensive care unit (NICU) • LPN/LVNs often work in Level II NICUs

4. Variations in Size and Gestational Age • Majority of newborns are born • Around 40 weeks’ gestation • Weighing from 5.5 to 10 lb (2.5 to 4.6 kg) • Measuring 18 inches to 23 inches (45 to 55 cm) in length • Variations in birth size and gestational age can increase the newborn’s risk for perinatal problems

5. Variations in Size and Gestational Age (cont.) • Size classifications consider the newborn’s weight, length, and head circumference • Small for gestational age (SGA) - Weight, length, and/or head circumference falls below the 10th percentile for gestational age • Appropriate for gestational age (AGA) - Weight, length, and/or head circumference falls between the 10th and 90th percentiles for gestational age • Large for gestational age (LGA) - weight, length, and/or head circumference is above the 90th percentile for gestational age • LO-#1

6. Variations in Size and Gestational Age (cont.) • Three classifications that describe a newborn’s size based on weight • Low birth-weight (LBW) • Weight less than 2,500 grams • Very low birth-weight (VLBW) • Weight less than 1,500 g • Extremely low birth-weight (ELBW) • Weight less than 1,000 g. LO#1

7. Variations in Size and Gestational Age (cont.) • Newborn classification based on gestational age includes • Preterm, or premature • Born at less than 37 weeks’ gestation • Post-term, or postmature • Born at greater than 42 weeks’ gestation • Term • Born between 37 and 42 weeks’ gestation LO#1

8. Gestational Age Assessment • Critical evaluation-RN is responsible, LPN needs to be familiar with instruments used and be able to differentiate characteristics of full-term newborn from those of premature or post-term newborn • Ballard scoring system-most common • Evaluation of two main categories of maturity: neuromuscular and physical maturity • Neuromuscular maturity-6 categories (score -1 to 5) • 1. Posture • 2. Square window (measurement of wrist angle with flexion toward forearm until resistance is met) • LO#2

9. Gestational Age Assessment (cont.) • Neuromuscular maturity (cont.) • 3. Arm recoil (extension and release of arm after arm is completely flexed and held in position for approximately 5 seconds) • 4. Popliteal angle (measurement of knee angle on flexion of thigh with extension of lower leg until resistance is met) • 5. Scarf sign (arm pulled gently in front of and across top portion of body until resistance is met) • 6. Heel to ear (movement of foot to near the head as possible) • LO#2

10. Gestational Age Assessment (cont.) • Physical maturity • 1. Skin • 2. Lanugo • 3. Plantar creases • 4. Breast buds • 5. Ears • 6. Genitals LO#2

11. Question When doing a gestational age assessment you gently pull the arm in front of and across the top portion of the body until resistance is met. What is this called? a. Square window b. Arm recoil c. Scarf sign d. Elbow angle

12. Answer c. Scarf sign Rationale: The scarf sign is performed by pulling the arm gently in front of and across the top portion of the body until resistance is met.

13. The Small-for-Gestational-Age (Growth-Restricted) Newborn • Intrauterine growth restriction (IUGR) • Occurs when the fetus does not receive adequate amounts of oxygen and nutrients • Can begin at any time during the pregnancy • Contributing factors • Inadequate maternal nutrition (mother not able to meet nutritional demands of pregnancy) • Abnormality in the placenta or its function (i.e. preeclampsia/eclampsia, uncontrolled diabetes) • Maternal smoking (most common preventable cause) • Fetal intrauterine infection (fetus is unable to use the supplied nutrients) LO#3

14. The Small-for-Gestational-Age (Growth-Restricted) Newborn (cont.) • Clinical manifestations • Two classifications of IUGR • 1. Symmetrical growth restriction- 20-30% • Both head and body parts are in proportion • More serious of the two types • Genetic cause • Condition is generally chronic LO#4

15. The Small-for-Gestational-Age (Growth-Restricted) Newborn (cont.) • Two classifications of IUGR (cont.) • 2. Asymmetrical growth restriction • Head is large in comparison with the body • IUGR newborn typically • Appears pale, thin, and wasted • Skin is loose and peeling • Face has a shrunken or “wizened” appearance • Skull sutures • Abdomen may be sunken

16. The Small-for-Gestational-Age (Growth-Restricted) Newborn (cont.) • IUGR newborn may have neurologic involvement • Cry may be shrill • Wide-eyed expression and appears hyperalert • May be irritable, jittery, and difficult to soothe • Exaggerated Moro reflex • Difficulty sleeping • Startles easily

17. The Small-for-Gestational-Age (Growth-Restricted) Newborn (cont.) • Complications • Aspiration of amniotic fluid • Meconium aspiration syndrome • Increased risk for cesarean delivery because of fetal distress • Difficulty with thermoregulation • Polycythemia LO#4

18. The Small-for-Gestational-Age (Growth-Restricted) Newborn (cont.) • Nursing care • RN is responsible for assessing gestational age, identifying potential complications, and initiating the plan of care • LPN/LVN, you play an important role in carrying out interventions identified in the plan of care • Be alert for potential complications and risk factors related to respiratory distress, hypothermia, hypoglycemia, polycythemia, and altered parental interaction with the newborn

19. The Large-for-Gestational Age Newborn • Newborn’s overall body size is proportional, but both head and weight fall in the upper limits of growth charts • Most genetically and nutritionally adequate • Size can be misleading • Contributing factors • Certain factors contribute • Maternal diabetes • Genetic makeup • Obesity and multiparity LO#5

20. The Large-for-Gestational Age Newborn (cont.) • Contributing factors (cont.) • Congenital disorders • Beckwith-Wiedemann syndrome-rare genetic disorder • Transposition of the great vessels • Umbilical abnormalities • Hypoglycemia and hyperinsulinemia of the newborn

21. The Large-for-Gestational Age Newborn (cont.) • Potential complications • More than twice as likely to deliver by cesarean section • Leading cause of breech presentation and shoulder dystocia • Fractured skull or clavicles • Cervical or brachial plexus injury • Erb palsy LO#5

22. The Large-for-Gestational Age Newborn (cont.) • Nursing care • Assist the RN to perform a gestational age assessment -monitor vital signs frequently, esp. respiratory status, S&S of hypoglycemia • Conduct and document routine nursing care • Document and report any signs of birth trauma or injury • Help parents verbalize feelings about any bruising or trauma they notice, including their fears of causing their newborn more pain • Encourage parent-newborn bonding

23. Question What is a characteristic of intrauterine growth restriction? a. Abdomen is distended b. Face appears shrunken c. Skin is tight to bones d. Extremities are not proportional

24. Answer b. Face appears shrunken Rationale: The IUGR newborn typically appears pale, thin, and wasted. The skin is loose and peeling with very little vernix. The face has a shrunken or “wizened” appearance. Skull sutures may overlap or be too wide, and the abdomen may be sunken. The umbilical cord appears thin and dull, compared with the shiny, plump cord of a normal newborn.

25. The Preterm Newborn • Needs and care differs with the level of prematurity • Micro-premies are the tiniest newborns, weighing less than 1,000 g. • Late preterm newborn born between 34 and 37 weeks’ gestation • Determining the gestational age of the preterm newborn is crucial • Transportation of the newborn may be necessary

26. The Preterm Newborn (cont.) • Contributing factors • Number of preterm births is actually on the rise • Advances in fertility treatments resulting in multiple births • Polyhydramnios • Larger than average intrauterine mass • Early cervical dilation • Preterm premature rupture of membranes (PPROM) LO#6

27. The Preterm Newborn (cont.) • Contributing factors (cont.) • Increased numbers of pregnant women with diabetes • Characteristics of the preterm newborn • The preterm infant is tiny, scrawny, and red • Extremities are thin • Head and abdomen are disproportionately large • Testes are undescended in the male • Many of the typical newborn reflexes are weak or absent LO#6

28. The Preterm Newborn (cont.) • Characteristics of the preterm newborn (cont.) • Physiologic immaturity causes many difficulties involving virtually all body systems, the most critical of which is the respiratory system • Thermoregulation and maintaining fluid and electrolyte balance (lack of subcutaneous and brown fat, newborn has increased surface area to body mass) • High caloric needs but has a digestive system that may be unprepared to receive and digest food (regurgitation or vomiting, immature liver) • Vulnerable to infection (does not receive enough antibodies from the mother) LO#6

29. The Preterm Newborn (cont.) • Characteristics of the preterm newborn (cont.) • Muscle weakness • Treatment of complications • Respiratory distress syndrome (RDS) • Intraventricular hemorrhage (IVH) • Retinopathy of prematurity (ROP) • Necrotizing enterocolitis (NEC) LO#8

30. Nursing Process for the Preterm Newborn • Assessment • Selected nursing diagnoses • Outcome identification and planning • Implementation • Improving respiratory function • Maintaining body temperature • Preventing infection

31. Nursing Process for the Preterm Newborn (cont.) • Implementation (cont.) • Protecting neurologic status • Maintaining fluid and electrolyte balance • Maintaining adequate nutrition • Sources of nutrition • Gavage feeding • Nipple (bottle) feeding

32. Nursing Process for the Preterm Newborn (cont.) • Implementation (cont.) • Preserving skin integrity • Promoting energy conservation • Supporting growth and development • Reducing parental anxiety • Improving parenting skills and family functioning • Evaluation: goals and expected outcomes LO#9

33. Question What is one of the characteristics of the preterm newborn? a. High caloric needs b. Low caloric needs c. Extremities are short and appear stunted d. Extremities appear longer than normal

34. Answer a. High caloric needs Rationale: High caloric needs but has a digestive system that may be unprepared to receive and digest food.

35. The Post-term Newborn • Contributing factors • Predisposing factors • First pregnancies between the ages of 15 and 19 years • Woman older than 35 years with multiple pregnancies • Certain fetal anomalies LO#10

36. The Post-term Newborn (cont.) • Characteristics of the post-term newborn • Little lanugo or vernix • Scalp hair is abundant • Fingernails are long • Little subcutaneous fat • Appears long and thin Lo#10

37. The Post-term Newborn (cont.) • Potential complications • Polycythemia • Meconium aspiration syndrome • Treatment • Nursing care • Ravenous eaters at birth • Monitor serial blood glucose levels • Provide a thermoneutral environment

38. Acquired Disorders • Respiratory disorders • Transient tachypnea of the newborn • Contributing factors-cesarean delivery, prematurity, SGA, maternal diabetes • Clinical manifestations and diagnosis-RR>60, mild retractions, nasal flaring, exp. grunting, difficulty breathing • Treatment-IV fluids, gavage-feeding, O2? • Nursing care-supportive (VS, sats) LO#11

39. Acquired Disorders (cont.) • Respiratory disorders (cont.) • Meconium aspiration syndrome • Clinical manifestations and diagnosis-low Apgar, tachypnea/apnea, retractions, cyanosis • Treatment-intubation if infant does not breathe immediately & suction below vocal cords; gastric lavage may be needed if infant breathes first • Nursing care-NICU & meds as ordered • Sudden infant death syndrome • Contributing factors-LBW, winter, males, young mothers, maternal smoking, prone sleeping • Treatment-SIDS is rapid, silent, & occurs any time • Nursing care-Grief counseling LO#11

40. Hemolytic Disease of the Newborn • Causes • Rh incompatibility • ABO incompatibility-typically milder • Diagnosis • Clinical manifestations • Treatment-mild to moderate-hydration & phototherapy; severely-NICU, usually receives an exchange transfusion immediately after birth • Nursing care-phototherapy • LO#12

41. Newborn of a Diabetic Mother • Clinical manifestations • Large for gestational age, plump and full-faced, bulky shoulders, and coated with vernixcaseosa • Placenta and the umbilical cord are oversized • Nursing care • Require especially careful observation • Watch for signs and symptoms LO#13

42. Newborn of a Mother with Substance Abuse • Fetal alcohol syndrome-is highly preventable • Clinical manifestations-hyperactive, irritable, tremors, seizures • Nursing care-supportive interventions (swaddling, decreasing sensory stimulation…) • Neonatal substance withdrawal • Clinical manifestations-tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing…) • Nursing care-physical and emotional support, medications (morphine, phenobarbitol, clonidine, methodone) LO#14

43. Newborn With a Congenitally Acquired Infection • All newborns are at increased risk for infections • A variety of organisms can cause newborn infection-Group B beta-hemolytic strep major cause, others: rubella, hep B, chlamydia, herpes, HIV • Treatment consists of intensive antibiotic therapy • IV fluids • Respiratory therapy • Other supportive measures • LO#15