Chapter 20 The Newborn at Risk: Gestational and Acquired Disorders

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

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 to 23 in (45 to 55 cm) in length Variations in birth size and gestational age can increase the newborn’s risk for perinatal problems

Variations in Size and Gestational Age (cont.) Size classifications considering newborn 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

Variations in Size and Gestational Age (cont.) Newborn weight-based classifications Low birth weight (LBW) Weight <2,500 g Very low birth weight (VLBW) Weight <1,500 g Extremely low birth weight (ELBW) Weight <1,000 g

Variations in Size and Gestational Age (cont.) Newborn gestational age Preterm, or premature Born at <37 weeks’ gestation Post-term, or postmature Born at >42 weeks’ gestation Term Born between 37 and 42 weeks’ gestation

Gestational Age Assessment Critical evaluation (RN responsibility; LV/PN assists) Ballard scoring system Evaluation of two main categories of maturity: Neuromuscular and physical maturity Neuromuscular maturity Posture Square window (measurement of wrist angle with flexion toward forearm until resistance is met)

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

Gestational Age Assessment (cont.) Physical maturity Skin Lanugo Plantar creases Breast buds Ears Genitals

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

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.

The Small-for-Gestational Age (Growth-Restricted) Newborn Intrauterine growth restriction (IUGR) Occurs when fetus receives inadequate amounts of oxygen and nutrients Can begin at any time during the pregnancy Contributing factors Inadequate maternal nutrition Abnormality in the placenta or placental function Maternal smoking Fetal intrauterine infection

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

The Small-for-Gestational Age (Growth-Restricted) Newborn (cont.) Clinical manifestations (cont.) Two classifications of IUGR (cont.) Asymmetrical growth restriction (70% to 80%) Head is large in comparison with the body IUGR newborn physical characteristics Appears pale, thin, and wasted Skin is loose, peeling; umbilicus thin and dull Face has a shrunken or “wizened” appearance Skull suture anomalies; abdomen may be sunken

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

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

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 plays 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

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 Maternal diabetes Genetic makeup Obesity Multiparity

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

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

The Large-for-Gestational Age Newborn (cont.) Nursing care Assist the RN to perform a gestational age assessment Conduct and document routine nursing care

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

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.

The Preterm Newborn Needs and care differs with level of prematurity Micropremies: Tiniest newborns, weighing <1,000 g Late preterm: Born between 34 and 37 weeks’ gestation Determining the gestational age of the preterm newborn is crucial Transport to NICU may be necessary Prematurity: Leading cause of perinatal death, disability

The Preterm Newborn (cont.) Contributing factors Number of preterm births is actually on the rise Advances in fertility treatments resulting in multiple births with Polyhydramnios; early cervical dilation Larger than average intrauterine mass Preterm premature rupture of membranes (PPROM) Increased number of pregnancies involving diabetes

The Preterm Newborn (cont.) Characteristics of the preterm newborn Preterm infant is tiny, scrawny, and red Extremities are thin with little muscle, subcutaneous fat Head, abdomen are disproportionately large Skin is thin, relatively translucent, wrinkled Abdominal, scalp veins more visible Testes are undescended in the male Many of the typical newborn reflexes are weak or absent

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 High caloric needs but has a digestive system that may be unprepared to receive and digest food Vulnerable to infection Muscle weakness

The Preterm Newborn (cont.) Treatment of complications Respiratory distress syndrome (RDS) Intraventricular hemorrhage (IVH) Retinopathy of prematurity (ROP) Necrotizing enterocolitis (NEC)

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

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

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

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

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

The Post-Term Newborn Contributing factors First pregnancies at ages of 15 to 19 years Woman older than 35 years with multiple pregnancies Certain fetal anomalies

The Post-Term Newborn (cont.) Physical characteristics of the post-term newborn Wide-eyed, hyperalert expression Little lanugo or vernix Scalp hair is abundant Fingernails are long Skin is dry, cracked, wrinkled, peeling, whiter than newborn’s Little subcutaneous fat Appears long and thin

The Post-Term Newborn (cont.) Potential complications Neonatal hypoglycemia Polycythemia MAS Treatment: Prevention Nursing care Ravenous eaters at birth; monitor serial blood glucose levels Provide thermoneutral environment

Acquired Disorders Respiratory disorders Transient tachypnea of the newborn (TTN) Contributing factors Clinical manifestations and diagnosis Treatment Nursing care

Acquired Disorders (cont.) Respiratory disorders (cont.) Meconium aspiration syndrome (MAS) Clinical manifestations and diagnosis Treatment Nursing care Sudden infant death syndrome (SIDS) Contributing factors Clinical manifestations

Hemolytic Disease of the Newborn Causes Rh incompatibility ABO incompatibility Diagnosis Clinical manifestations Treatment Nursing care

Newborn of a Diabetic Mother Clinical manifestations (type 2) LGA; plump, full faced with bulky shoulders Coated with vernix caseosa; placenta, umbilical cord are oversized Clinical manifestations (type 1): IUGR Nursing care Require especially careful observation Watch for signs and symptoms

Newborn of a Mother with Substance Abuse Fetal alcohol syndrome Clinical manifestations Nursing care Neonatal substance withdrawal Medications to ease withdrawal, prevent seizures, as ordered

Newborn with a Congenitally Acquired Infection All newborns are at increased risk for infections A variety of organisms can cause newborn infection Treatment Intensive antibiotic therapy IV fluids Respiratory therapy Other supportive measures