NURSING CARE OF HIGH-RISK CHILD-NEWBORN

8 NEWBORN PRIORITIES IN THE

1ST DAYS OF LIFE
• Initiation& maintenance of
respirations
• Establishment of extra
uterine circulation
• Control of body
temperature
• Intake of adequate
nourishment
• Establishment of waste
1. INIATIATING &
elimination
MAINTANING
• Prevention of infection
RESPIRATIONS
• Establishment of infant-
• Most deaths occur during
parent relationship
the 1st 48 hours after birth
• Developmental care, or
• Due to NB’s inability to
care that balances
establish & maintain
physiologic needs &
respirations
stimulation for best
development FACTORS predisposing infants to
respiratory difficulty in the 1st few
days of life
• LBW,
• maternal DM,
• PROM,
• maternal use of
barbiturates or narcotics
close to birth,
• Irregularities in FHT,
• cord prolapse,
• meconium staining,
• low APGAR (<7),
• post maturity,
• SGA,
• Breech birth,
• multiple birth,

OB LECTURE 1
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• chest, heart, or respiratory will increase the need for

tract anomalies O2
• If AF is meconium-stained,
RESUSCITATION
do NOT stimulate NB to
• If respirations do not begin,
breathe by rubbing the
respiratory acidosis will
increase; by 2 minutes, back or administering O
severe respiratory acidosis under pressure (it could
develops push meconium further
• Resuscitation becomes down the airway).
necessary. • Give O2, without pressure
• Resuscitation follows an • wait for a laryngoscope to
organized process: be passed & the trachea
a) establish and suctioned before giving O2
maintain an airway under pressure
b) expand the lungs;
and
c) initiate & maintain
effective ventilation
• If respiratory depression
becomes severe, the heart
will fail then cardiac massage
• Do NOT suction longer than
is necessary
10 seconds
A. AIRWAY
• Suction gently!
• Bulb syringe to aspirate B. LUNG EXPANSION
mucus & amniotic fluid from
• Crying is proof that lung
the mouth & nose- not
expansion is good because
routinely done
the vocal sounds are
• If the Nb does not draw in a
produced by a free flow of
1st breath spontaneously,
air over the vocal cords
suction the mouth & nose
• A NB who breathes
with a bulb syringe again &
spontaneously but cannot
rub the back to see if skin
sustain effective
stimulation initiates
respirations may need O2
respiration
by bag & mask to aid
• Make sure the infant is dry
respiration
to prevent chilling since it

OB LECTURE 2
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• The mask should cover

BOTH the mouth & nose to
D. VENTILATION
be effective
MAINTENANCE
• Increasing RR is often the 1st
often the 1st sign of
obstruction or respiratory
compromise
• Retractions - inward
sucking of the anterior
chest wall on inspiration
• A NB with difficulty
• It should not cover the eyes maintaining respirations
• Administer 100% O2; O2 should be placed under an
should be warmed & infant warmer & have the
humidified weight of clothing removed
• Fluctuating O2 levels cause from the chest. Keeping
rupture of immature cranial warm prevents acidosis
blood vessels & excessive • Position the NB on the back
pressure can rupture lung with the head of the
alveoli mattress elevated about 15
• Monitor O2 level with pulse degrees to allow abdominal
oximetry & auscultate both contents to fall away from
lungs the diaphragm
C. DRUG THERAPY • Suction secretions &
• If respiratory depression is monitor O2 levels
due to maternal use of • If NB has no audible
narcotics (morphine or heartbeat, or if HR is < 60
meperidine), administer a 2. ESTABLISHING
narcotic antagonist such as EXTRAUTERINE
naloxone (Narcan) injected CIRCULATION
into an umbilical vessel or bpm, start closed-chest
IM massage
• usually, 0.01 to 0.1 mg/kg • Hold infant with fingers
BW supporting the back &
depress the sternum with 2

OB LECTURE 3
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

fingers (depress about 1/3 • Hypovolemia symptoms:

of its depth, 1 to 2 cm) hypotension, tachycardia,
• If heart sounds are not tachypnea, ↓ CVP, ↓
resumed > 60 bpm after 30 peripheral tissue perfusion,
sec of CPR, 0.1 to 0.3 ml/kg developing acidosis
of epinephrine (1:10,000) • NSS or Lactated Ringer’s
may be sprayed into the ET solution may be given to
tube to stimulate cardiac increase blood volume
function B. REGULATING
A. MAINTANING FLUID & TEMPERATURE
ELECTROLYTE • Neutral temperature
BALANCE environment (not too hot
• After initial resuscitation nor too cold) places less
attempt, hypoglycemia demand to maintain a
may result from the effort minimal metabolic rate
expended to begin • Upon chilling, the increased
breathing metabolism requires
• Dehydration may result increased O2, or the cells
from increased insensible will become hypoxic
H2O loss from rapid • To save O2,
respirations vasoconstriction occurs; if
• Fluids given: Ringer’ s prolonged, pulmonary
lactate or 10% dextrose in perfusion decreases, pO2
H2O; Na, K & glucose may level falls, CO2 level
be added increases
• Very high fluid intakes can • ↓ pO2 may open fetal R-to-
lead to PDA or heart failure L shunts, surfactant
• Monitor urine output & production halts
urine specific gravity; UO < • To supply glucose for the ↑
2 ml/kg/hour or a sp. in metabolism, anaerobic
Gravity > 1.015 to 1.020 glycolysis occurs which
suggests dehydration pours acid into the
• If hypovolemic, maybe due bloodstream
to fetal blood loss (placenta • The infant becomes acidotic
previa or twin-to-twin increasing the chance for
transfusion) kernicterus as more

OB LECTURE 4
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

bilirubin is free to pass into

the bloodstream
• Wipe the NB dry, cover the
head with a cap, place
immediately under a
prewarmed radiant
warmer or in a warmed
incubator or skin-to-skin
contact
• Maintain infant’s axillary KANGAROO CARE
temperature at 97.8°F
(36.5° C)
• Avoid placing infant directly
on cool x-ray tables, scales,
etc.
C. RADIANT HEAT
SOURCES
• Radiant heat warmers -
open beds with overhead
radiant
• It is the use of skin-to-skin
• source: include
contact to maintain body
Servocontrol probes placed
heat.
on the skin to continuously
• Infant is undressed except
monitor temperature
for a diaper & head cap
• Probe should be taped into
• The parent sits on a chair &
the abdomen between the
holds the infant snugly
umbilicus & xiphoid process
against the chest, skin-to-
• If temperature falls below
skin
95.9°F to 97.7°F, an alarm
• Both are covered with a
will sound
blanket for privacy
• A plastic bridge or shield
placed over the child will
reduce convection &
radiation losses.
• Additional warming pad
placed under an infant

OB LECTURE 5
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

D. ESTABLISHING E. ESTABLISHING WASTE

ADEQUATE ELIMINATION
NUTRITIONAL INTAKE • Must void within 24 hours
• Infants who had severe of birth
asphyxia at birth usually F. PREVENTING
receive IVF to prevent INFECTION
exhaustion from sucking or • Infection increases
until NEC has been ruled metabolic demands,
out stresses the immature
• If tachypneic and NEC (-), immune system
gavage feeding • Common microbes:
• Gavage-fed - need oral cytomegalovirus,
stimulation from toxoplasmosis,
nonnutritive sources- • Infections: GBS septicemia,
should be given a pacifier thrush, herpes infections
at feeding times • Prevention: good
• Exceptions: too immature handwashing techniques,
to have a sucking reflex, skin care
those with TEF awaiting G. ESTABLISHING
surgery PARENT-INFANT
BONDING

OB LECTURE 6
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

percentiles of weight for

their age regardless of
gestational age
• SMALL FOR GESTATIONAL
AGE(SGA) – infants who
fall below the 10th
percentile of weight for their
age
• LARGE FOR GESTATIONAL
AGE (LGA) - infants who
fall above the 90th
percentile in weight
• LOW BIRTH WEIGHT
INFANTS (LBW) - infants
weighing < 2,500 g
• VERY-LOW-BIRTH-
WEIGHT (VLBW) - infants
THE NEWBORN AT RISK
BECAUSE OF ALTERED weighing 1,000 to 1,500 g
GESTATIONAL AGE OR BIRTH • EXTREMELY-VERY-LOW-
WEIGHT BIRTHWEIGHT (EVLBW) -
• COLORADO INTRAUTERINE those weighing from 500 to
GROWTH CHART - used to 1,000 g
plot the birth weight
1. THE SMALL FOR
• TERM INFANTS – born after
GESTATIONAL AGE
the beginning of week 38
INFANT (SGA)
and before week 42
(calculated from the 1st day
of the LMP)
• PRETERM INFANTS – born
less than the 37th week
• POSTTERM INFANTS - born
after the onset of week 43
• APPROPRIATE FOR
GESTATIONAL AGE (AGA)
- infants whose BW’s fall
between the 10th and 90th

OB LECTURE 7
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• They are small for their age • Poor biophysical

because they have profile
experienced intrauterine II. APPEARANCE
growth retardation or failed • below average in
to grow at the expected weight, length, HC
rate in utero (if deprivation
occurs late in
CAUSES OF SGA
pregnancy,
• Poor nutrition of mother
reduction only in
• Pregnant adolescent - with
weight)
own nutritional and growth
• overall wasted
needs + increased needs of
appearance
pregnancy
• Small liver -
• Placental anomaly - either
difficulty regulating
the placenta did not obtain
glucose, protein &
enough nutrients, or it was
bilirubin levels after
inefficient at transporting
birth
nutrients to the fetus -
• Poor skin turgor
placental damage- partial
• Appears to have a
placental separation,
large head because
developmental defects of
the body is so small
the placenta
• Skull sutures may
• Systemic diseases - DM,
be widely separated
PIH where the blood vessel
from lack of normal
lumens are narrowed
bone growth
• Mothers who smoke or take
• Hair is dull and
narcotics
lusterless
• Intrauterine infection
• Abdomen may be
• Chromosomal
sunken
abnormalities
• Cord appears dry &
ASSESSMENT OF SGA: may be stained
I. PRENATAL ASSESSMENT: yellow
• Fundal height is III. LABORATORY FINDINGS
progressively less • High hematocrit
than expected due to lack of fluid in
utero and

OB LECTURE 8
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

polycythemia (due CAUSES OF LGA

to anoxia) • overproduction of growth
• Acrocyanosis may hormone in utero (mothers
be prolonged and who are obese or with DM)
persistent • Multiparous women
• Hypoglycemia is a • Other conditions:
common problem transposition of great
2. LGA or vessels, Beckwith-
MACROSOMIA Wiedemann syndrome,
omphalocele

• Weight is above the 90th

percentile on an
intrauterine growth chart

OB LECTURE 9
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

ASSESSMENT OF LGA CARDIOVASCULAR

• Size of uterus is unusually DYSFUNCTION
large for the date of • hyperbilirubinemia due to
pregnancy absorption of blood from
• CS may be necessary due bruising & polycythemia
to CPD (biparietal diameter • Polycythemia is to fully
is closer to 10 than the usual oxygenate all body tissues
9 cm) or shoulder dystocia • Great stress on the heart so
• Do a non-stress test monitor the heart rate
• If (+) for cyanosis, may be a
APPEARANCE
sign of Transposition of
great vessels

HYPOGLYCEMIA
• Monitor in the early hours
because the Nb uses up
nutritional stores readily to
sustain weight
• If mom has DM, fetus is
used to high blood glucose
levels causing increased
• Immature reflexes or low production of insulin. After
scores on gestational age birth, increased insulin
examinations in relation to levels continue for up to 2
his or her size hours causing rebound
• Extensive bruising or birth hypoglycemia
injury (broken clavicle or 3. PRETERM INFANT
Erb- Duchenne
• Paralysis from trauma
• Prominent caput
succedaneum or
cephalhematoma or
molding

OB LECTURE 10
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• An infant born before the • Reproductive system

end of week 37 of gestation abnormalities of the mother
• Another criterion is a • Infections (esp. UTI)
weight < 2,500 g (5 lb. 8 • Obstetric complications
oz) at birth (PROM, abruption
• Maturity is determined by placenta)
physical findings like sole • Early induction of labor
creases, skull firmness, ear • Elective CS
cartilage, and neurologic
ASSESSMENT
findings as well as the LMP
• Small & underdeveloped
and UTZ results
• Head is disproportionately
• Preterm babies need to be
large (3 cm or more > chest
differentiated from SGA
size)
infants; PT babies are
• Ruddy skin - little SC fat,
immature and small but
veins are noticeable, high
well-proportioned for age
degree of acrocyanosis
• Most are LBW infants
• Very preterm NB’s (24 to 26
CAUSES weeks) have no vernix
• Low socioeconomic level • Extensive lanugo covering
due to inadequate nutrition the back, forearms,
• Poor nutritional status forehead, and sides of face
• Lack of prenatal care • Anterior & posterior
• Multiple pregnancy fontanelles are small
• Previous early birth • Few or no sole creases
• Race (non-whites have a • Eyes appear small bur
higher incidence) papillary reaction is present
• Age of mother (highest in • Myopia due to lack of eye
those < 20 years old) globe depth
• Cigarette smoking • Ear cartilage is immature &
• Order of birth (highest in 1st allows pinna to fall forward;
pregnancies & beyond ears are large in relation to
• the 4th pregnancy) the head
• Closely – spaced • Neurologic function is
pregnancies immature

OB LECTURE 11
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• If <33 weeks, absent sucking KERNICTERUS

reflex diminished DTR
• Less active than mature Nb
& rarely cries (weak & high-
pitched)

POTENTIAL COMPLICATIONS OF
PREMATURITY

ANEMIA of Prematurity
• Low reticulocyte count
because the BM does not
increase production until 32
weeks
• Pale, lethargic, anorexic
• Immaturity of the
hematopoietic system+ RBC • It is the destruction of brain
hemolysis due to low levels cells by invasion of direct
of Vitamin E which protects bilirubin in the blood from
RBCs against oxidation excessive hemolysis
MANAGEMENT • Preterm infants are more
• Avoid excessive drawing of prone because of the
blood acidosis which makes the
• ERYTHROPOIETIN brain cells more susceptible
• Blood transfusions • Preterm have less serum
• Vitamin E albumin to bind indirect
• Iron provided by a preterm Bilirubin to inactivate its
formula effect
• Kernicterus may occur at
lower levels (as low as 12
mg/ 100 ml of Indirect
bilirubin)
• Managed by phototherapy
or exchange transfusion to
lessen indirect bilirubin
levels

OB LECTURE 12
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

PERSISTENT PATENT DUCTUS • Due to fragile capillaries

ARTERIOSUS and immature cerebral
vascular development
• Rapid changes in cerebral
BP (hypoxia, IV infusions,
ventilation, or
pneumothorax) cause
capillaries to rupture
• Brain anoxia occurs distal
to the rupture
• Hydrocephalus may occur
from obstruction of the
• Preterm lack surfactant aqueduct
thus have difficulty in
OTHER Potential Complications:
moving blood from the
• Respiratory distress
pulmonary artery to the
syndrome
lungs.
• Apnea
• It leads to pulmonary artery
• Retinopathy of prematurity
hypertension which may
• Necrotizing enterocolitis
interfere with the closure of
the DA MANAGEMENT of PTs
• Minimize maternal
MANAGEMENT of PPDA
anesthesia and analgesia
• Administer IVT cautiously to
to help initiate initial breath
avoid increasing BP
(within 2 minutes after
• Indomethacin helps close
birth)
the DA (side effect: oliguria;
• Monitor urine output for the
monitor urine output)
1st few days
• Ibuprophen may also close
• Monitor blood glucose q 4 to
the DA
6 h (NR is 40 to 60mg/100
PERIVENTRICULAR / ml)
INTRACENTRICULAR • IV Fluids given within hours
HEMORRHAGE to fulfill fluid & glucose
• It is bleeding into the tissue requirements
surrounding the ventricles • TPN until stable
or into the ventricles

OB LECTURE 13
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• Breast, gavage, or bottle 4. POST TERM INFANT

feedings begin as soon as
NB tolerates them to
prevent deterioration of
intestinal villi
• Offer a pacifier during
gavage feedings to
strengthen sucking reflex
• Gavage feedings are given
every few hours or
continuously via tubes
passed through the nose or
mouth (1 ml/hr.) • Born after the 42 nd week of
• Breast milk may be given pregnancy
via gavage feeding to • Labor is usually induced at
prevent NEC 2 weeks post term to avoid
• Preterm need 115 to 140 postmature births
calories/kg BW/day • At risk because the
placenta functions
effectively only for 40 weeks

POST TERM INFANT

CHARACTERICTICS
• Newborn emaciated
• Meconium stained
• Hair and nails long
• Dry peeling skin
• Creases cover soles
• Limited vernix and lanugo

POST TERM SYNDROME

• Dry, cracked, almost
leather-like skin from lack
of fluid
• Absent vernix

OB LECTURE 14
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• Lightweight due to weight

loss because of poor
ILLNESS IN THE NEWBORN
placental perfusion
• 1. RESPIRATORY
• Meconium-stained DISTRESS SYNDROME
amniotic fluid
• Fingernails grown beyond
the end of fingertips
• Alertness like a 2-week-old
baby
• Low SC fat deposits- poor
temperature regulation
• Hypoglycemia may develop
having used up stores of
glycogen
• Polycythemia due to lack of
O2

MANAGEMENT
• NST or BPP when
pregnancy becomes post
term
• Control or prevent • Formerly HYALINE
hypoglycemia/ meconium MEMBRANE DISEASE
aspiration common in preterm, infants
• Follow-up care to check of diabetic moms, CS birth,
neurologic symptoms that meconium aspiration
may have occurred due to • Pathologic feature: hyaline-
lack of nutrients and O2 in like (fibrous) membrane
utero formed from an exudate of
the infant’s blood

OB LECTURE 15
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

CAUSE • Poor perfusion depresses

production of surfactant
even more
• Poor O2 exchange levels
lead to tissue hypoxia,
releasing lactic acid. This,
plus ↑ CO2 causes
formation of the hyaline
membrane on the alveolar
surface leading to severe
acidosis
• Acidosis causes
vasoconstriction,
decreased pulmonary
perfusion & further limits
surfactant production
• The vicious cycle continues
• lack of surfactant until gas exchange
• Surfactant forms on the becomes inadequate to
34th week of gestation sustain life without
ventilator support
PATHOPHYSIOLOGY
• 40 to 70 cm H2O is required ASSESSMENT
for the initial breath but • Difficulty initiating
only 15 to 20 cm H2O to respirations at birth
maintain quiet respirations • Low body temperature
• If alveoli collapse with each • Nasal flaring
respiration, forceful • Sternal & subcostal
inspirations are required to retractions
inflate them • Tachypnea (>60
• Areas of hypo inflation respirations per minute)
begin to occur and ↑ • Cyanotic mucous
pulmonary resistance membranes
causing blood to shunt • Periods of apnea
through the FO and the DA • Bradycardia
• Pneumothorax

OB LECTURE 16
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• Expiratory grunting (due to

closure of the glottis)
• Fine rales & diminished
breath sounds
• Seesaw respirations (on
inspiration, anterior chest
wall retracts & abdomen
protrudes, on expiration,
sternum rises)
• Heart failure, evidenced by
decreased urine output &
edema of extremities
SILVERMAN-ANDERSEN INDEX • Pale gray skin
1. CHEST MOVEMENT
0 – synchronized resp DIAGNOSIS
1 - lag on resp • Clinical signs: grunting,
2 - seesaw resp cyanosis in room air,
2. INTERCOSTAL tachypnea, nasal flaring,
RETRACTION retractions & shock
0 - none • Chest x ray: diffuse pattern
1 - just visible of radiopaque areas
2 - marked resembling ground glass
3. XIPHOID RETRACTION (haziness)
0 - none • Blood gas reveals
1 - just visible respiratory acidosis
2 - marked • ß-hemolytic streptococcal
4. NARES DILATATION infection may mimic RDS.
0 – none Cultures may be done to
1 - minimal rule this out and antibiotics
2 – marked (penicillin or ampicillin)
5. EXPIRATORY GRUNTING may be given while culture
0 - none reports are pending
1 - audible
2 - audible (unaided ear)

OB LECTURE 17
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

THERAPEUTICAL MANAGEMENT • COMPLICATION:

• Retinopathy of Prematurity
• Bronchopulmonary
Dysplasia

• Surfactant Replacement
• Immediately given after
• Additional Therapy
birth, synthetic surfactant is
• Nitric Oxide
administered into the ET
• It causes pulmonary
tube by a syringe or
vasodilation without
catheter (lung lavage)
decreasing systemic
• Position: Tippled to an
vascular tone by dilating
upright position
pulmonary arterioles
• Adjust ventilator setting to
• EXTRACORPOREAL
accommodate the vastly
MEMBRANE
improved lung function
OXYGENATION (ECMO) -
• Oxygen Administration
blood is removed by gravity
• To maintain correct PO2
using a venous catheter in
and pH levels ff surfactant the right atrium of the
administration. heart. The blood circulates
• Can be administered by: to the ECMO machine,
➢ O2 Cannula or Mask where it is oxygenated &
➢ CPAP rewarmed. It is then
➢ Assisted Ventilation returned to the aortic arch
with through a catheter
➢ PEEP

OB LECTURE 18
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

advanced through the surface, and gas exchange

carotid artery occurs
• Currently used in Severe • Nitric oxide - it caused
Hypoxemia related to pulmonary vasodilation
Meconium Aspiration, RDS, which help increase blood
Pneumonia, Diaphragmatic flow to the lungs
Hernia • Keep infant warm to
prevent acidosis & reduce
metabolic demand

2. TRANSIENT
TACHYPNEA OF THE
NEWBORN
• At birth, RR reaches 80
bpm; after 1 hour, RR slows
down to 30 to 60 cpm
• In some RR remains high at
80 to 120 cpm
PREVENTION • Infant does not appear to
• Monitor L/S ratio during be in distress aside from the
pregnancy (Normal is 2:1) effort of breathing rapidly
• Avoid premature L &D • Mild retractions but not
(tocolytic agents) marked cyanosis
• BETAMETHASONE, a is • Mild hypoxia and
given to the mother at 12 & hypercapnia
24 hours. It is most effective • Feeding may be difficult due
when given between 24 to to tachypnea
34 weeks of pregnancy. It • TTN may result from slow
does not take effect before absorption of lung fluid,
24 to 48hours slight decrease in
• Liquid ventilation - use of surfactant production
perfluorocarbons which limiting alveolar surface for
picks up O2 and because gas exchange
they are heavy, help • Common in CS delivered
distend the alveoli; the infants
liquid spreads over the lung

OB LECTURE 19
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• O2 administration may be ASSESSMENT

necessary • If AF is meconium-stained,
• Typically fades by 72 hours suction with a bulb or
after birth catheter while at the
perineum
3. MECONIUM
• Do not administer O2 under
ASPIRATION
pressure (bag & mask) until
SYNDROME
intubated & suctioned
• Meconium is present in the
• CXR shows bilateral coarse
fetal bowel as early as 10
infiltrates in the lungs with
weeks
spaces of hyperaeration
• Fetal hypoxia causes vagal
(HONEYCOMB
reflex relaxation of the
APPEARANCE)
sphincter muscles,
• Tachypnea, retractions,
releasing meconium into
barrel chest due to air
the amniotic fluid
trapping, abnormal blood
• At birth, AF appears green
to greenish black MANAGEMENT
• Aspiration can cause • AMNIOINFUSION to dilute
severe RD in 3 ways: the amount of AF & reduce
inflammation of risk of aspiration
bronchioles because it is a • Tracheal suction, O2
foreign substance; can administration & assisted
block small bronchioles by ventilation
mechanical plugging; • Antibiotic therapy to
decrease surfactant prevent pneumonia
production by lung cell • Observe for signs of heart
trauma failure
• Hypoxia, CO2 retention & • Maintain a temperature-
intrapulmonary neutral environment
&extrapulmonary shunting • Chest physiotherapy to
occur encourage removal of
• Secondary infection of meconium
injured tissue may lead to • ECMO
pneumonia

OB LECTURE 20
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

be given to stimulate
4. APNEA
respirations by increasing
• It is a pause in respiration
sensitivity to CO2
longer than 20 seconds
• Infants who had severe
with accompanying
apneic episodes have a
bradycardia and beginning
high risk for SIDS & are
cyanosis
discharged home with a
• In preterm, due to
monitoring device to be
immaturity of respiratory
used for 2 to 6 months
mechanisms and fatigue
5. SUDDEN INFANT
• Common in babies with
DEATH SYNDROME
secondary stresses such as
(SIDS)
infections,
• SIDS is a sudden
hyperbilirubinemia,
unexplained death in
hypoglycemia, or
infancy
hypothermia
• CAUSE: Unknown
MANAGEMENT
RISK FACTORS
• Gently shaking or flicking
• Adolescent mothers
the sole of the foot often
• Closely spaced pregnancies
stimulates breathing
• Underweight & preterm
• Apnea monitors sound
infants
alarms
• Infants with
• Maintain a neutral
bronchopulmonary
environment, use gentle
dysplasia
handling
• Twins
• Suction gently to prevent
• Alaskans, Native
irritation & vagal
Americans, economically
stimulation
disadvantaged black
• Observe infant after feeding
infants
• Never take rectal
• Narcotic-dependent
temperature to avoid vaga
mothers
stimulation
• Prolonged but unexplained
• THEOPHYLLINE or
apnea
CAFFEINE SODIUM
BENZOATE or • Viral respiratory or
botulism infection
METHYLXANTHINES may

OB LECTURE 21
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• Pulmonary edema 6. APPARENT LIFE-

• Brainstem abnormalities THREATENING
• Neurotransmitter EVENT.
deficiencies • Episode where the infant is
• Heart rate abnormalities discovered cyanotic & limp
• Distorted familial breathing but have survived after
patterns mouth-to-mouth
• Decreased arousal resuscitation
responses • Apnea monitoring is
• Possible lack of surfactant recommended
in the alveoli • Teach parents CPR before
• Sleeping in a room without discharge from the hospital
moving air currents 7. PERIVENTRICULAR
(respiratory muscles are LEUKOMALACIA
restricted) (PVL)
ASSESSMENT
• Blood-flecked sputum or
vomitus in the mouth of the
dead infant
• Autopsy reveals petechiae
in the lungs & mild
inflammation & congestion
of the respiratory tract • PVL is
abnormal
MANAGEMENT formation of
• Prevention: put NB’s to the white
sleep on their backs or matter of the
sides brain caused
• Parents should be by an
counseled by trained ischemic episode that
personnel interferes with circulation to
• Autopsy reports should be a portion of the brain.
given to parents as soon as Phagocytes &
possible macrophages invade the
area to clear away necrotic
tissue leaving a hollow

OB LECTURE 22
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• space (seen via UTZ) infant’s RBC’s, leading to

hemolysis causing severe
anemia and
hyperbilirubinemia

10. Rh INCOMPATIBILITY
• Mother is Rh (D) negative,
exposure to fetal Rh (+)
blood will stimulate the
mother to form antibodies
against the D antigen
• Most form within 72 hours
• Frequent in preterm who after delivery due to active
experience cerebral exchange of blood
ischemia • Due to the sensitization, in a
• No therapy 2nd pregnancy, there will
• Infants may die or be left be a high level of antibodies
with long-term effects like circulating in the maternal
learning disabilities bloodstream which destroy
fetal RBC’s early in the
PREVENTION
pregnancy if the fetus is Rh
• Reduce environmental
(+)
stimuli or sudden shifts in
cerebral blood flow by MANAGEMENT
avoiding rapid fluid • Intrauterine transfusions
infusions or sudden noises • Induced preterm labor
8. HYPERBILIRUBINEMIA • Phenobarbital given to the
• An elevated level of bilirubin mother to induce liver
in the blood resulting from maturity for easy
RBC hemolysis conversion of IB to DB
9. HEMOLYTIC DISEASE
OF THE NEWBORN
• ABO or Rh incompatibilities
• The mother builds
antibodies against the

OB LECTURE 23
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

11. ABO THERAPEUTIC MANAGEMENT

INCOMPATIBILITY • Initiation of early feeding to
• Maternal blood type is O remove bilirubin from the
and fetal blood type is A body through the feces by
(most common), B(most stimulating peristalsis
serious) or AB • Home phototherapy - to
• Hemolysis is a problem with decrease physiologic
the 1st pregnancy in which jaundice
ab’s to A or B are naturally • Transcutaneous
occurring bilirubinometer - handheld
• antibodies are of the large fiberoptic light placed
type (Ig M) & cannot cross against the infant’s skin to
the placenta unlike anti-D measure intensity of the
abs jaundice
• Infant is not born anemic; • Phototherapy - exposure to
hemolysis begins at birth light triggers liver to convert
when mixing of blood IB to DB
occurs • Continuous exposure to
specialized light like quartz
ASSESSMENT
halogen, cool white daylight
• Rising anti-Rh titer (indirect
or special blue, fluorescent
Coomb’s test) on the
light
mother
• Lights are 12 to 30 inches
• Positive direct Comb’s test
from the infant’s bassinet
(Rh abs found on fetal RBCs
• Specialized fiberoptic light
in cord blood)
systems incorporated into a
• Enlarged liver & spleen
fiberoptic blanket
• Edema (hydrops fetalis)
• Progressive jaundice
occurring within the 1st 24
hours of life

COMPLICATION
• KERNICTERUS (level of IB >
20 mg/dl)

OB LECTURE 24
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

EXCHANGE
TRANSFUSION

• Undressed except for a

diaper (to protect ovaries • Albumin may be given 1 to 2
or testes) to expose as hours before the procedure
much skin surface as to increase bilirubin-
possible binding sites & also to
• Eyes must be covered to increase efficiency of the
protect the retina procedure
• Stools are bright green due • Blood given is Type O Rh (-)
to excretion of excessive ➢ monitor VS during
bilirubin the procedure
• Urine may be dark-colored ➢ after the procedure
due to urobilinogen observe for
• Infant should be removed umbilical vessel
from the light & remove eye bleeding or infection
patches during feeding for
bonding 12. HEMORRHAGIC
DISEASE OF THE
NEWBORN
• From lack of Vitamin K
essential for formation of
prothrombin
• Vitamin K is formed by the
action of bacteria in the
intestines
• NB’s with vitamin K
deficiency show petechiae
from superficial bleeding

OB LECTURE 25
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

into the skin, conjunctiva, • Occurs in 1/3 of all identical

mucous membrane or twins
retinal hemorrhage, vomit • Shift of blood results to
fresh blood or pass black, anemia in the donor twin &
tarry stools polycythemia in the
• Vitamin K deficiency recipient
usually occurs on day 2 to • The anemic twin may be
day 5 when prothrombin SGA due to lack of O2 &
levels are lowest nutrients for growth &
• Prevented by IM 1 mg of prone to hypoglycemia
Vitamin K immediately
after birth
• Treatment: IV or IM Vitamin
K, transfusion of fresh,
whole blood

13. TWIN-TO-TWIN
TRANSFUSION

• The anemic twin is pale

while the polycythemic twin
is prone to
hyperbilirubinemia
• Identified in utero by
sonogram because 1 twin is
noticeably larger
• A difference of > 5 g/ 100 ml
is enough to suggest that a
• Occurs in monozygotic transfusion occurred
twins (identical; share the • Donor twin may need
same placenta) and if transfusion to establish
abnormal arteriovenous functioning blood level
shunts occur that direct • Recipient twin may need
more blood to 1 twin than exchange transfusion to
the other reduce polycythemia and
viscosity of blood

OB LECTURE 26
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

retinal detachment &

14. NECROTIZING blindness
ENTEROCOLITIS • Infants who are most
• The bowel develops immature & receive the
necrotic patches interfering most O2 are at highest risk
with digestion & possibly
leading to paralytic ileus.
Perforation & peritonitis
may follow

• Preterm receiving O2 must

have pO2 levels monitored
by pulse oximeter,
transcutaneous O2
• Pneumatosis intestinalis saturation, or blood gas
monitoring
15. RETINOPATHY OF • Keep oxygen within normal
RPEMATURITY levels to decrease the risk
• It is an acquired ocular • When levels of pO2 > 100
disease that leads to partial mm Hg, risk is high
or total blindness due to
16. THE NEWBORN AT
vasoconstriction of
RISK BECAUSE OF
immature retinal blood
MATERNAL
vessels
INFECTION OR
• Immature retinal vessels
ILLNESS
constrict when exposed to
high O2 concentrations • Ability to produce
• In addition, endothelial cells antibodies is immature
in the layer of nerve fibers in
the periphery of the retina
proliferate, leading to

OB LECTURE 27
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

A. BETA-HEMOLYTIC,
GROUP B
THERAPEUTIC MANAGEMENT
STREPTOCOCCAL
• If screening is positive,
INFECTION
antibiotics are given
•
• Gentamycin, penicillin,
• GBS is a natural inhabitant
ampicillin is effective
of the female genital tract
• If mother is GBS (+) during
late pregnancy, IV
ampicillin is given at 28
weeks and again at labor to
reduce possibility of
exposure

ASSESSMENT
• High- risk NB’s (after
prolonged rupture of=
membranes or mother’s
B. OPTHTHLAMIA
vaginal culture is positive)
NEONATORUM
may be asymptomatic
• Illness may be early or late
• It is an eye infection that
onset
occurs at birth or within the
• Early onset: signs of
1st month
pneumonia within 1st day of
• Most common causes:
life as well as apnea,
Neisseria gonorrhea,
tachypnea, signs of shock
Chlamydia trachomatis
(oliguria, pallor, hypotonia);
• Progresses to corneal
20% DIE WITHN 1ST 24
ulceration & destruction
HOURS OF BIRTH
CXR like RDS: ground glass
appearance
• Late onset may occur at 2
to 4 weeks of age; instead of
pneumonia, meningitis
occurs (lethargy, bulging
fontanels, fever, anorexia

OB LECTURE 28
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

C. GONORRHEA • eyes are irrigated with

sterile saline solution to
clear the discharge
• use a sterile dropper, or
bulb syringe; use barrier
protection
• solution should be at room
temperature
• direct fluid laterally to
prevent contaminating
another eye
ASSESSMENT • mother must be treated to
• Usually, bilateral prevent sterility
• Conjunctiva are fiery red D. HEPATITIS B
with thick pus, eyelids INFCETION
edematous • Transmitted through
• Usually occurs within 1st 4 contact with infected
days of life but possible vaginal blood at birth
when infant has • Infants are routinely
conjunctivitis within 1st vaccinated at birth
month of life (30 days) • If mother is HBsAg (+), infant
is administered immune
PREVENTION
serum globulin (HBIg)
• Prophylactic instillation of within 12 hours of birth
erythromycin ointment into • Infant should be bathed as
the eyes of NBs soon as possible to remove
• Delayed until after the 1st blood & secretions
period of reactivity for • Gentle suctioning to
bonding prevent trauma to the
THERAPEUTIC MANAGEMENT mucous membranes
• If due to gonococci, IV • HBV is transmitted in
ceftriazone and penicillin breastmilk, but once Ig has
• If due to Chlamydia, been established, women
ophthalmic solution of may breast feed without
erythromycin risk to the infants

OB LECTURE 29
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

E. GENERALIZED
HERPESVIRUS
INFECTION
• Herpes simplex virus type 2
(HSV-2) is prevalent among
women with multiple sexual
partners
• Can cross the placental
barrier but mostly
• Vesicles are clustered,
contracted from vaginal
pinpoint in size surrounded
secretions during delivery
by a reddened base
ASSESSMENT • after vesicles rupture,
• Vesicles cover the skin infants become extremely
• Long-term prognosis is ill with dyspnea, jaundice &
guarded because severe shock.
neurologic damage may • Death may occur within
have occurred hours or days
simultaneously • those who survive may
• If acquired at birth, at 4th to suffer permanent CNS
7th day they show anorexia, sequelae
low-grade fever, lethargy
THERAPEUTIC MANAGEMENT
• Stomatitis or a few vesicles
• Acyclovir (Zovirax)
on the skin occur
(inhibits DNA synthesis) is
given
• CS birth is advised
• infected infants must be
separated from other
infants
• women with herpes lesions
on their face should not
hold or feed their infants
until the lesions have
crusted over

OB LECTURE 30
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

F. HIV

• CANDIDIASIS

• Stages:
• KAPOSI’ S SARCOMA
➢ Initial invasion of
virus with mild,
flulike symptoms
• Seroconversion-
production of antibodies vs
HIV happens in 6 wks to 1
year
➢ Asymptomatic
period for 3 to 11
years
• Symptomatic period during DIAGNOSIS (HIV/AIDS)
which a woman develops • ELISA antibody reaction -
opportunistic infections presumptive
and possibly malignancies • Western Blot analysis -
(toxoplasmosis, confirmatory
candidiasis, GIT, illnesses, 20-50% of infants born to
herpes simplex, Kaposi untreated HIV + women will
sarcoma, HIV- associated contract the virus & develop
dementia). At this point, AIDS in the 1st year of life
CD4 count is usually below
200 cells/mm3 MANAGEMENT
• Progression of the disease is
assessed by frequent CD4
cell counts(q 3 mos.) The
goal is: CD4 cell count > 500
cells/ mm3

OB LECTURE 31
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• Meds: (In addition to oral

ZVD during pregnancy IV
during labor & delivery), 1 or
more protease inhibitors
like ritonavir (Norvir) or
indinavir (Crivixan) in
conjunction with a
nucleoside reverse
transcriptase inhibitor drug
• Educate client on safe sex
• Macrosomia is due to
practices, testing of sex
overstimulation of pituitary
partners
growth hormone & extra fat
• Monitor client for signs of
deposits due to high levels
opportunistic infection:
of insulin in utero
fever, weight loss, fatigue,
• Most are immature though
candidiasis, cough, skin
large
lesions
• High fetal insulin blocks
G. INFANT OF A
cortisol release blocking
DIABETIC MOTHER formation of lecithin
• If DM was poorly controlled, preventing lung maturity
infant is longer & larger • Infant loses a great
(macrosomic) proportion of weight in the
• Increased chance of 1st few days due to extra
congenital anomaly such as fluid accumulated
cardiac anomaly
• CAUDAL REGRESSION FETAL COMPLICATIONS
SYNDROME - hypoplasia of • Shoulder & neck injury
lower exteremities occurs • CPD
almost exclusively • Immediately after birth,
• Cushingoid appearance hyperglycemic then glucose
(fat & puffy) levels fall due to lack of
• Lethargic & limp due to supply & overproduction of
hyperglycemia insulin
• Hyperbilirubinemia if
immature due to immature
liver
• Hypocalcemia because
parathyroid hormonesare

OB LECTURE 32
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

lower due to • Vomiting & diarrhea,

hypomagnesemia from leading to large fluid losses
excessive renal loss of & secondary dehydration
magnesium • Opiate withdrawal: signs
begin 24 to 48 hours after
THERAPEUTIC MANAGEMENT
birth, up to 10 days
• Avoid hypoglycemia (levels ➢ Lasts up to 2 weeks
below 40 mg/dl) by early • Heroin – addicted NB’s:
feeding with formula or signs appear within the 1st 2
administered continuous weeks of life
infusion of glucose
• Check for abdominal MANAGEMENT
distention indicating a • Swaddling makes them
smaller-than-usual colon comfortable
H. INFANT OF A DRUG- • Lessen environmental
DEPENDENT MOTHER stimuli
• Usually SGA, showing • Maintain F & E balance
withdrawal symptoms • Drugs used for withdrawal:
(neonatal abstinence paregoric, Phenobarbital,
syndrome) methadone,
chlorpromazine, &
NAS SYMPTOMS diazepam
• Irritability I. AN INFANT WITH
• Disturbed sleep pattern FETAL ALCOHOL
• Constant movement SYNDORME
possibly leading to
abrasions on the elbows,
knees, etc.
• Tremors
• Frequent sneezing
• Shrill, high-pitched cry
• Possible hyperreflexia &
clonus (neuromuscular
irritability)
• Convulsions • Alcohol crosses the
• Tachypnea, possibly so placental barrier in the
severe it lay lead to same concentration as in
hyperventilation & alkalosis the maternal blood stream

OB LECTURE 33
NURSING CARE OF HIGH-RISK CHILD-NEWBORN

• No safe threshold for

alcohol so avoid alcohol
during pregnancy

SYMPTOMS
• Pre- & postnatal growth
restriction
• CNS involvement (cognitive
challenge, microcephaly,
cerebral palsy)
• Short palpebral fissure
• Thin upper lip
• Tremulous
• Irritable
• Weak sucking reflex
• Always asleep or always
awakeS

LONGTERM EFFECTS
• Hyperactivity
• Growth deficiencies

OB LECTURE 34