NURS 137 - TheHighRiskNeonate

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The High Risk Neonate
M E R E D I T HW I L L I A M S ,R N , B S N

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

disease

DM
HTN
Hypothyroid
renal



disease

Exposure to environmental factors
toxic

chemicals
illicit drugs

At Risk Newborns


Maternal Factors
age
parity



Pregnancy complications
placenta

abruption
placenta previa
oligohydramnios
preterm labor
premature rupture of membranes
pre-eclampsia
uterine 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 gestation
Poor reserve – temp instability or hypoglycemia
Poor feeding – poor latch or < 10 min at breast
Weight 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 supplementation
 Lactation 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_ca re_standards/obste
trics/XVI-50.shtml
World Health Organization. (2013). Preterm birth. Retrieved from
http://www.who.int/mediacentre/factsheets/fs363/en/

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