1. Chapter 20 The Newborn at Risk: Gestational and Acquired Disorders

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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)

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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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.

24. 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

25. 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

26. 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

27. 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

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

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

30. 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

31. 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

32. 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

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

34. 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

35. 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

36. 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

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

38. 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

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

40. 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

41. 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

42. 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