Chapter 17

Nursing Care of the Newborn at Risk

CARE OF THE NEWBORN AT RISK B/C OF BIRTH ASPHYXIA
 Birth asphyxia also known as perinatal asphyxia, asphyxia neonatorum, or hypoxic-ischemic encephalopathy
o Acute brain injury c/b asphyxia when baby did not get enough 02 during birth
o Possible causes of asphyxia during the birth process include the following:
 Mother does not get enough oxy. during labor.
 Mother’s BP is too high/too low during labor.
 Placenta separates from uterus too quickly → loss of O2
 Umbilical cord becomes wrapped too tightly around neck or body.
 Fetus is anemic & does not have enough RBCs to tolerate labor contractions.
 NB airway becomes blocked.
 Delivery is too long or difficult.
 When baby becomes asphyxiated & breathing slows/ceases, there is lack of perfusion of blood to brain & other organ
systems → Hypoxia forces cells to undergo anaerobic respiration, which produces less energy than aerobic respiration
 Lactic acid forms as by-product of cellular respiration, the cells cannot function normally, & tissues become
affected/damaged
o Initially, the lack of 02 affects the brain, muscles, & heart → heart dysfunction causes HoTN, leading to damage in a
variety of organs
 If adequate blood perfusion returns, newborn’s brain can begin to swell, which causes more neurological
problems.
 At birth, infant may exhibit:
o Cyanosis
o Diff. breathing
o Gasping respirations
o Umbilical cord blood pH less than 7
o Apgar score of less than 3 for more than 5 min
 The newborn with birth asphyxia may be transferred to the NICU if symptoms are severe or persist
o Medical management
 BP management w/ medications
 Ventilation support & 02 therapy if needed
 Careful fluid management
 Avoidance of hypoglycemia or hyperglycemia
 Avoidance of hyperthermia
 Tx. of seizures
 Hypothermia therapy followed by slow rewarming to reduce brain swelling
o Nursing Care
 Adm. medications & fluids
 Monitoring ventilation & oxygenation of baby
 Monitoring fluid balance
 Monitor & report signs of hypoglycemia, hyperglycemia, & hyperthermia
o Long-Term Complications
 Cerebral palsy
 Epilepsy
 Blindness
 Delayed motor development
 Intellectual disability / Learning disabilities

CARE OF THE NEWBORN WITH RESPIRATORY DISTRESS

 Can be caused by:
o Asphyxia at birth
o A lack of surfactant in lungs w/ a premature birth
o Fluid in lungs → Meconium aspiration
o Pulmonary HTN
o Cold stress
RESPIRATORY DISTRESS SYNDOME OF THE NEWBORN
  Respiratory distress syndrome (RDS) caused by lack of surfactant in & immaturity of fetal lungs. → seen in premature
infants, can occur in also in NB experiencing birth asphyxia, born to diabetic mothers, & born by C/S
 RDS was formerly known as hyaline membrane syndrome b/c of formation of hyaline membranes that line alveoli &
impair ventilation.
o surfactant in lungs ⇣ surface tension in alveoli & keep open for ventilation → If surfactant absent hypoxemia &
hypercapnia (elevated C02) occur, leading to respiratory acidosis → Acidosis causes vasoconstriction &
damages epithelium of lungs, causing formation of a hyaline membrane inside alveoli that impairs O2 exchange.
 The signs of RDS will be evident either at birth or within 8 hours of life
o Common signs are:
 Tachypnea or Dyspnea
 Grunting w/ expirations
 Nasal flaring
 Intercostal retractions
 Cyanosis
o Medica management
 administration of antenatal corticosteroids will ↓ risk of RDS
 Surfactant therapy OR Oxygen therapy
 Continuous positive airway pressure (CPAP) to keep alveoli open at end of respiration
 Mechanical ventilation support if needed
 Vapotherm: heated & humidified high-flow 02 through a NC
o Nursing interventions
 Administering neonatal cardiopulmonary resuscitation (CPR) if indicated
 Administering medications & fluids
 Monitoring respiratory & oxygenation status
 Providing emotional support to family
TRANSIENT TACHYPENIA OF THE NEWBORN (TTN)
 TTN is a self-limiting condition in which tachypnea, ⇡ oxygen needs, & mild respiratory distress occur
o TTN occurs more often in infants who:
 sedated from maternal pain medications in labor
 prolonged labor
 Macrosomia
 babies born via C/S
 TNN caused by incomplete reabsorption of fluid in the lungs & usually resolves within 3-5 days
 Care of the infant with TNN
o Medical management
 Supportive care with IV fluids & gavage feedings until RR has decreased enough to allow breast/bottle
feedings
 Oxygen support to maintain 02 saturation levels above 93%
 Chest x-ray
 Arterial blood gas (ABG)
o Nursing interventions
 Administering & monitoring IV fluids
 Monitoring oxygenation by physical assessment, ABGs, & O2 saturation levels
 Administering gavage feedings
 Minimizing stimulation
 Preventing hypothermia/hyperthermia
 Providing emotional support to family
 After TTN has resolved, focusing on bonding & breastfeeding support
MECONIUM ASPIRATION SYNDROME
 During L&D fetus may become stressed by placental insufficiency, cord compression, or infection. → Decrease O2 &
cause fetus to pass meconium into amniotic fluid
o Meconium is rarely found in amniotic fluid prior to 34 weeks’ gestation & mainly affects term & post-term
newborns
o The meconium can block infant’s bronchioles → Causing poor oxygenation, pneumonia, & pneumothorax
(collapsed lung).
 Observe the infant for signs of possible meconium aspiration → If newborn progresses into respiratory distress, endotracheal
intubation & mechanical ventilation may be required
 o greenish-yellow staining of the skin, nailbeds, or umbilical cord:
o Tachypnea
o Retractions
o Nasal flaring
o Grunting
o Decreased oxygen saturation levels
o Decreased breath sounds
o If present at birth, thorough suctioning should occur with the first breath
PERSISTENT PULMONARY HTN OF THE NEWBORN (PPHN)
 When baby is delivered & takes 1st breath, fetal circulation begins transition to normal circulation → Blood flows from
right ventricle into pulmonary arteries to capillaries in alveoli for gas exchange → O2 is picked up & CO2 is released
 In PPHN, the fetal circulation persists, or remains, as it was in uterus → Ductus arteriosus and/or foramen ovale remain
open, blood is shunted away from lungs causing high pressure → inadequate blood flow to lungs for oxygenation
 Common causes
o Perinatal asphyxia
o RDS
o Neonatal sepsis
o Congenital defect of heart or lungs
 S/S
o cyanosis that does not improve w/ administration of oxygen
o symptoms of shock (HoTN & tachycardia)
o possibility of heart murmur c/b open ductus arteriosus and/or foramen ovale
 Medical management
o Echocardiography → a test that looks at how blood flows through heart vessels, valves, & chambers to dx heart defects
o Chest x-ray to dx. lung defects
o ABGs to monitor oxygenation
o Oxygen therapy
o Dopamine to elevate BP
o Surfactant, if caused by lung Dx.
o Vasodilators after infant is stable to reduce lung HTN
o Mechanical ventilation
 Nursing Care
o Adm. medications
o Continuous monitoring of vitals & oxygenation
o Maintain normal body temp.
o Nutritional support
o Minimal handling of newborn to reduce O2 consumption
o Teaching & emotional support of the family
 Prognosis of PPHN depends upon initial cause → May resolve, or NB may have ongoing health problems → higher risk
of neurosensory hearing loss & neurodevelopmental problems

CARE OF THE NEWBORN WITH COLD STRESS

 The risk of cold stress is highest during immediate transitional period after birth → Normal rectal temperature for term &
preterm infants is 36.5°C to 37°C (97.7°F-98.6°F).
 Risk Factors
o Premature infants
o Small-for-gestational-age (SGA)
o Infants who require resuscitation
o NB w/ infection or a congenital anomaly
o Born outside hospital environment
 When infant’s body temperature drops, the body attempts to adapt & raise temperature by:
 Peripheral vasoconstriction → conserves heat for core of body.
 Core blood volume increases → causing an increase in HR & BP
 Increase in metabolic rate → increased 02 needs & hypoglycemia
 Brown fat is metabolized → causing a release of fatty acids & subsequent acidosis.
 S/S
o Temperature below 36.3°C (97.7°F)
 o Weak cry
o Respirations that become slow & shallow
o Jitters from low blood sugar
o Refusal to eat
o Lethargy
o Respiratory distress
 Interventions
o Monitor temp. every 15 minutes
o Providing skin-to-skin contact w/ mom OR Placing in incubator & gradually rewarming
o Placing infant under a radiant warmer
o Double-wrapping newborn → Using special rewarming blankets
o Infusing warmed IV fluids
o If bottle-fed, warm formula

NEONATAL HYPOGLYCEMIA
 a plasma glucose level of less than 30 mg/dL in the 1st 24 hours of life & less than 45 mg/dL thereafter.
 Risk Factors
o Premature or postmature NB
o Infant of a diabetic mother (IDM)
o Small-for-gestational-age (SGA) OR Large-for-gestational-age (LGA) infant
o Infant stressed at birth (cold stress or asphyxia)
 S/S
o Jitteriness or tremors
o Lethargy or irritability
o Hypotonia
o Weak or high-pitched cry
o Apnea
o Hypothermia
o Poor feeding
 Interventions
o Obtaining blood sample via heel stick ASAP after birth for high-risk infants; if results are normal, repeating 30
minutes, 1 hour, 2 hours, 4 hours, 8 hours, and 12 hours after birth
o If glucometer reading is between 30 and 40 mg/dL, the infant should be breastfed or bottle-fed → Recheck blood
glucose 20 min. after feeding
o If less than 30 mg/dL, follow hospital protocol; & possible blood draw for STAT blood glucose, adm. of glucose gel,
or IV administration of D10W (10% dextrose in water)
 Newborns need glucose for energy, & 95% of available glucose is used for brain function → Long-term complications
from frequent/prolonged hypoglycemia are neurological damage (intellectual disability, developmental delays, personality
disorders, ⇣ head size, & seizures)
 Be aware that the NB blood glucose levels can drop if newborn:
 Has no glycogen stored in the liver (a (premature NB)
 Has used up stored glucose for heat production or a birth stress (aphagia)
 Infant of a diabetic mother (IDM) & has hyperinsulinism
 Cannot feed enough to keep glucose level in acceptable range
 Check blood sugar immediately after birth for any large or small birth-weight newborn
 Glucose gel can be effective in treating hypoglycemia w/o undermining breastfeeding & applied to NB Buccal Mucosa
after feeding

CARE OF THE NEWBORN W/ BIRTH INJURIES

 Known as Birth trauma result of traction & compression during birth
 Risk factors for birth trauma include the following:
o Fetal macrosomia
o Cephalopelvic disproportion
o Prolonged or very rapid delivery
o Forceps or vacuum extraction
o Abnormal presentation (breech)
o Large fetal head
  Common soft-tissue injuries are cephalohematoma, caput succedaneum, & abrasion or lacerations from instrumental
deliveries
o These injuries resolve within days & cause no long-term problems for infant
BRACHIAL PLEXUS INJURIES
 Brachial plexus injury to the NB occurs from ↑ in infant’s neck-shoulder angle, resulting in a traction force to brachial
plexus → brachial plexus is a network of nerves that originate in neck & branch off to form nerves that control movement &
sensation in shoulders, arms, & hands
o associated w/ large birth weight, long labors, vaginal breech delivery, and shoulder dystocia
 Symptoms of brachial plexus injury are:
o Limited movement on one side of body
o No Moro reflex on affected side
o Clawlike appearance of newborn’s hand on affected side
o Abnormal muscle ctx. on affected side
 diagnosis of a brachial plexus injury → x-rays to determine if there is a fracture of the clavicle, shoulder, or arm;
imaging studies; & nerve conduction studies
o Medical management may include:
 Physical therapy such as ROM (massage, & stretching to help infant develop muscles on affected side)
 Surgical treatment → grafting a nerve from a less used muscle to affected area
o Nursing Care
 Report symptoms of a brachial plexus injury immediately
 Protect affected arm from dangling when held/moved → No lifting infant under axillae
 Teaching parents to support affected arm w/ rolled blankets when infant is in car seat & crib
 Monitoring for signs of pain & reporting to HCP (neonate pain scale)
 Positioning w/ good body alignment to prevent complications from muscle contractures
 Providing emotional support to family
FRACTURES
 The clavicle most frequently fractured bone in NB ⇢ Injury is associated w/ macrosomic & lg. shoulder infants =
vaginal delivery difficult
o After delivery, NB may not move affected arm & a palpable bone irregularity may be noticed during physical assessment → also
look for possible brachial plexus injury
 Healing occurs in 7-10 days → To decrease pain, the arm is immobilized by using safety pins to attach undershirt sleeve to shirt

HYPERBILIRUBINEMIA
 Pathological or nonphysiological jaundice: some infants serum bilirubin level rises excessively → bilirubin is excessively
elevated, skin becomes saturated w/ bilirubin, causing yellow color → Kernicterus: After skin saturated, bilirubin begins to deposit
in brain & can cause neurotoxicity
 Risk factors for pathological jaundice:
o Prematurity
o A blood-type incompatibility w/ the mother
o Lack of effective breastfeeding
o Excessive bruising from an extended labor or a malpresentation in labor, such as face presentation
 Jaundice can usually be detected visually when level reaches 5 to 6 mg → 1st appears on face & sclera may be tinted yellow
→ as levels ↑ yellow color spreads down body.
 A transcutaneous bilirubinometer → noninvasive instrument that gives estimate of total bilirubin before serum bilirubin
test done
 Medical management is based upon the infant’s gestational age, weight, & bilirubin level
o Breastfeeding will help w/ ↓ bilirubin levels → by eliminating through GI tract & kidneys
 Phototherapy using a “blue light” converts bilirubin into water-soluble compounds that are excreted by body
o Infant can be exposed to the blue light through overhead lights, pads, or blankets → & can be removed from light for
feedings, b/c important for Tx.
 Blood exchange transfusion may be required if bilirubin levels rising quickly & kernicterus occurs → neurological
damage may result if levels do not drop w/ feedings & phototherapy
 Nursing interventions:
o Encouraging breastfeeding 8-12 times/day or bottle feeding 8-10 times/day.
o Monitor # stools
o Weigh diapers to obtain urine output. (least 6 wet diapers & 3 stools per/day)
o Place eye patches on NB eyes to protect retina damage from phototherapy light
o Undress NB except for genital area to expose max. amt. of skin to light
 o Monitor NB behavior; irritability or lethargy could be signs that bilirubin level is irritating brain
o Monitor body temp. for hypothermia from being undressed

CARE OF NEWBORN W/ AN INFECTION

 Exposure to infection from organisms that enter vagina during labor, contaminated hospital personnel & equipment, &
from family/visitors
o A newborn has an immature immune system & body unable to attack against a severe infection before it becomes systemic.
SEPSIS
 Neonatal sepsis → blood infection that presents within 1st 28 days
 Invasive infection which chemicals released into blood to help fight infection cause inflammation in body.
 Common Pathogens → are group B streptococcus (GBS), Escherichia coli, and herpes → found in hospital environment,
maternal flora, or community
o Who at risk?
 Preterm newborns
 Maternal infection w/ GBS
 Amniotic membranes ruptured for longer than 24 hours
 Chorioamnionitis (infection of amniotic membranes)
 Frequent vaginal examinations during labor; which examiner inadvertently transports E. coli from rectal area into
vagina & cervix
o S/S of Neonatal sepsis
 Poor temperature control (hypothermia or hyperthermia)
 Irregular respirations
 Dyspnea / Expiratory grunting & retractions
 “See-saw” retractions (the abdomen lifts & the chest sinks)
 Cold clammy skin
 Abnormal heartbeat
 Lethargy
 Poor feeding
 Diminished activity or hyperactivity
 Bulging fontanel
 Diarrhea
 Abdominal distention
o Medical management
 Cardiopulmonary support
 IV fluids OR placement of central venous line for antibiotic adm. (aminoglycosides, penicillins, and
vancomycin)
 Antiviral medication, such as acyclovir, may be given if infection from herpes
 IV parenteral nutrition (PN) during acute phase to support the immune system as well as growth &
development

o Interventions
 Monitoring vitals & Lab results, & report abnormal finding
 Promote thermoregulation
 Adm. IV fluids, antibiotics, antiviral medications, & PN
 Monitoring fluid balance
 Supporting the family & provide opportunities for bonding
HERPES
 Herpes virus type 2 (genital herpes) is most common cause of herpes infection in newborn → type 1 (oral herpes) can also
cause infection
 The newborn may only develop a skin infection that blisters, crusts over, & then heals. → herpes infection can become
systemic (neonatal sepsis & is life-threatening)
 Symptoms & Medical management & interventions are the same, except for antibiotics → Antibiotics are not effective
against a virus

CARE OF NEWBORNS WITH PROBLEMS RELATED TO GESTATIONAL AGE &

DEVELOPMENT
 Length of term pregnancy is 40 wks., measured from 1st day of last menstrual period to estimated date of delivery
SMALL-FOR-GETATIONAL-AGE (SGA) / INTRAUTERINE GROWTH RESTRICTION (IUGR) NEWBORN
 A small-for-gestational age (SGA) NB is an infant whose weight is less than 10th percentile for gestational age
 Possible causes of SGA
o Abnormalities of placenta or vessels that restricted nutrients & oxygen to developing fetus → limit growth c/b ⇣ placenta
perfusion
o Maternal HTN
o Uncontrolled, severe maternal diabetes
o Poor maternal nutrition
o Maternal drug use / exposure to teratogenic substances
o Heavy maternal smoking/ alcohol consumption
o Multi-gestation
o Parents of small stature
 Term SGA infants do not have complications related to immature organs as a premature baby does but are at risk for
other complications:
o Perinatal asphyxia during labor if SGA was caused by placental insufficiency; fetus may not receive enough 02 during
stress of labor.
o During asphyxia infant may pass meconium into amniotic fluid & aspirate it into lungs at birth, causing respiratory distress.
o Hypoglycemia may occur b/c ack of stored glycogen. → Neonatal hypoglycemia is a plasma glucose level of less than 30
mg/dL in 1st 24 hours of life & less than 45 mg/dL after
o Hypothermia may occur b/c of lack of sub-Q fat
 Nursing interventions for SGA
o Perform gestational age assessment
o Observe respiratory distress
o Detect tremors or jitteriness (early signs of hypoglycemia) → Instituting early feeding to prevent hypoglycemia
o Monitor for hypothermia
o Monitoring vitals & daily weight
o Teaching parents about need to keep the infant warm & provide frequent feedings
 Prognosis for a Small-for-Gestational-Age Newborn
o If asphyxia was avoided at birth → neurological prognosis for SGA infant is excellent.
o If growth restriction was b/c of placental insufficiency, adequate nutrition after birth will allow infant to “catch up.”
o SGA situation caused by maternal drug use or smoking may contribute to a smaller child & adult.
 IUGR is dx. when HCP measures fundal height & through ultrasound examinations → If poor placental perfusion is the
cause, labor may be induced & baby is delivered early.
 Physical findings of an infant diagnosed with IUGR include the following
o Weight, length, & head circumference below 10th percentile for gestational age
o Large head in relationship to rest of body
o Thin extremities & trunk
o Loose skin caused by absence of sub-Q fat
o Thin umbilical cord
LARGE-FOR-GESTAIONAL-AGE (LGA) NEWBORN
 The large-for-gestational-age (LGA) NB weight is greater than 90th percentile for gestational age → The predominant
cause of LGA is maternal diabetes
 Most common complications for LGA newborns are:
o Shoulder dystocia OR fracture of clavicle/limbs
o Perinatal asphyxia
o Meconium aspiration
o Respiratory distress
o Hypoglycemia
o Vag delivery
 Assessment findings:
o Large/obese NB
o Listless, apathetic baby
 Nursing interventions for LGA
o Perform gestational age assessment
o Assess respiratory status
o Asses for signs of birth injuries & report immediately
o Monitoring for tremors (early sign of hypoglycemia) →Providing frequent feedings to ⇣ risk of hypoglycemia
PRETERM NEWBORN
 Preterm infants are born before 37 weeks’ gestation
 Sometimes the cause of a premature birth is unknown
o Risk factors include
 Low socioeconomic status
 Cigarette smoking
 Prior premature births
 Multiple prior therapeutic or spontaneous abortions
 Little/No prenatal care
 Poor nutrition
 Untreated infections
 Pre-eclampsia
 Multiple gestation
 The Ballard Gestational Age Assessment Tool is used to determine gestational age
o During physical assessment of premature NB nurse will notice
 Skin is thin, arteries & veins are visible.
 Skin is fragile & looks smooth/shiny.
 Moderately premature infant will have abundant lanugo.
 Fingernails & toenails may only be partially formed.
 Ears may fold over b/c cartilage has not developed.
 Very preterm has less muscle tone.
 Premature baby does not lie in a “fetal position” until 35 weeks.
 Potential complications
o Respiratory distress. → immature respiratory system lacks surfactant to keep alveoli open.
o Hypothermia. → Thermoregulation is difficult for premature infant b/c of lack of sub-Q fat & infant may not have
developed brown fat to assist w/ heat production during stress. → Cold stress occurs easily in premature newborn.
o Heart problems → Most common problems are patent ductus arteriosus (PDA) & HoTN →. PDA supposed to close
on own to allow more blood flow to lungs; but in premature infant, it may stay open, causing HF
o intraventricular hemorrhage in brain → Very premature infant, these can occur b/c fragile, underdeveloped blood
vessels in brain rupture & bleed into ventricles .
 For intraventricular hemorrhage in brain, there is no way to stop bleeding → The prognosis depends
upon the amount of bleeding that occurs & if there is accompanying swelling of brain
 There may be no symptoms, or the nurse may observe & :
 Apnea
 Decreased muscle tone/reflexes
 Excessive sleep
 Weak suck
 Seizure
 Health care team will keep infant stable & treat symptoms
o Necrotizing enterocolitis. associated w/ formula feeding & characterized by damage to intestinal tract that may have
occurred from abnormal intestinal flora, immaturity of intestinal mucosa, intestinal ischemia caused by decreased placental
blood flow & a genetic predisposition →damage may affect only the mucosal lining, or there may be full-thickness necrosis
& perforation of the bowel
o Anemia. → infants experience a drop in RBCs after birth, but it may be more profound for premature infant so frequent
blood draws are required for tests.
o Infection. → B/c of premature baby’s immature immune system, infection can spread quickly to bloodstream → sepsis.
o Fluid and electrolyte imbalances . → d/t immature circulatory & renal systems. so monitor IV fluid intake & electrolytes to
prevent fluid overload & HF.
o Apnea of prematurity. → apnea (cessation of breathing for more than 20 seconds less than 20 sec. (bradycardia or 02 stat
levels of less than 85%). →r/t immature and/or depression of central respiratory drive to stimulate muscles of
respiration
 Medical management tactile stimulation, adm 02, use of continuous positive airway pressure (CPAP), &
pharmacotherapy.
o Retinopathy of prematurity (ROP). → Premature birth results in cessation of normal growth of blood vessels of retina →
Long-term outcomes visual impairment & blindness.
 All premature infants are tested for retinopathy. Early surgical laser Tx.
o Cerebral palsy. → disorder of muscle tone & movement c/b infection or inadequate blood flow to premature
infant’s brain..
  Delayed development. → In beginning, premature babies usually behind on meeting developmental
milestones (risk for learning disabilities & are likely to have neurological problems (ADHD)) → most will
catch up by 12-18 months
 To obtain corrected age, subtract baby’s number of wks. (or months) of prematurity from his or her
actual age in wks. (or months).
 For example, a baby born 2 months premature who is 6 months old would be expected to meet
developmental milestones for a 4-month old baby.
POST-TERM NEWBORN
 A post-term NB is born after 42 weeks’ gestation → Cause of postmaturity unknown, but previous post-term delivery ⇡
risk
o Fetal growth btw. 39 & 43 weeks’ gestation results in a large infant
o In some cases, the placenta begins to detach & break down, causing placental insufficiency syndrome → Fetus
receives inadequate nutrition & 02 from placenta, resulting in SGA & undernourished
 The fetus may use stored glycogen for energy before birth. → amniotic fluid volume begins to ⇣ w/
postmaturity
 Gestational age assessment done to confirm that NB is postmature
o Physical characteristics of a postmature NB:
 More alert after birth than term infant
 Decreased sub-Q fat & Loose skin
 Dry & peeling skin
 Lack of vernix & lanugo
 Long fingernails & toenails
 Meconium staining on umbilical cord
o Possible complications
 Stillbirth or neonatal death is increased in post-term.
 Larger body size can lead to prolonged labor & birth trauma.
 Hypoglycemia d/t lack of stored glycogen.
 Increased risk of meconium aspiration in uterus b/c of stress

CARE OF THE INFANT OF A DIABETIC MOTHER (IDM)

 Neonatal complications for the IDM are r/t inadequate glucose control in pregnancy & lead to → Fetal malformations
(cardiomegaly that occur b/c of poor glucose control in 1st trimester.)
o High glucose levels late pregnancy can lead to macrosomia, hypoglycemia, hypoxia, polycythemia, &
hypocalcemia/hypomagnesemia.
CONGENTIAL MALFORMATIONS
 High blood-sugar concentrations are toxic to cell growth in 1 st trimester of pregnancy & can cause cardiac & CNS
abnormalities of fetus
 Cardiomegaly w/ an enlarged left ventricle & there is increased risk of spina bifida for IDM
o Nursing interventions
 Promptly identifying the congenital abnormality, if obvious, at birth & Notifying HCP of physical
abnormalities or abnormal vitals
FETAL MACROSOMIA
 Infant weighing more than 4,000 g at birth, occurs in diabetic pregnancies
 High levels of maternal glucose during gestation → fetal hyperglycemia & hyperinsulinemia (excess insulin), which
causes ⇡ growth in fetus
 If delivered vaginally, the Lg. infant is at risk for birth injuries caused by shoulder dystocia
 At delivery, the macrosomic IDM appears ruddy (reddish), fat, & puffy & may have ⇣ muscle tone
 Nursing interventions
o Notifying pediatrician or pediatric NP of birth weight & signs of macrosomia
o Perform gestational age assessment
o Observe for signs of birth injuries
o Observing for signs of hypoglycemia
HYPOGLYCEMIA
 IDMs often have a rapid fall in glucose within 1 Hr. of birth → ⇡ maternal glucose crosses placenta & insulin does not,
resulting in hyperinsulinism
 When umbilical cord cut, glucose from mother is stopped & fetus is left w/ high levels of circulating insulin, causing
hypoglycemia
FETAL HYPOXIA
 Uncontrolled high glucose levels can cause vascular dx. In mother, leading to decreased blood flow to placenta → fetus
needs more 02 d/t ⇡ maternal glucose therefore, fetal hypoxia occurs (decrease supply of 02 to tissues) / Chronic hypoxia
can lead to intrauterine death or respiratory distress
 Polycythemia → Fetus in uterus attempts to compensate for ⇣ 02 by producing extra RBCs
POLYCTHEMIA
 Polycythemia dx. When Hct is greater than 65% → Extra cells make blood thicker & stickier, which can cause strokes or
seizures in NB
 Polycythemia also contributes to ⇡ risk of hyperbilirubinemia after birth, when extra RBC break down & immature liver
cannot manage breakdown of bilirubin.
 Signs of polycythemia in newborn:
o A “ruddy” (red) appearance of skin
o Sluggish capillary refill time / Cyanosis
o Respiratory distress
o Poor feeding
o Lethargy
o Seizures
o Apnea
o Hematuria
 Medical management
o Vitals, Hct, & blood glucose are monitored frequently
o Some physicians will perform a partial blood exchange transfusion w/ saline to ⇣ Hct quickly in symptomatic
infants. → Asymptomatic infants, common approach is to observe for onset of symptoms & let body adjust to Hct
 Some physicians will hydrate the newborn w/ IV fluids to decrease Hct.
 Nursing interventions
o Notifying HCP immediately of any S/S of polycythemia
o Infuse IV fluids (help flush out infant) & observe for signs of fluid overload
 Calculate appropriate fluid amounts based upon the infant’s weight → confirm calculations w/ 1 other
licensed nurse.

CARE OF CHEMICALLY EXPOSED INFANTS

 Early gestation → drugs can have a teratogenic effect, causing structural birth defects
 When fetal development complete, drugs have a subtler effect → alterations in neurotransmitters, their receptors, &
brain organization
 Drug toxicology screen on NB urine, cord blood, or meconium done to plan appropriate care while in withdrawal
 Neonatal abstinence syndrome (NAS) is group of similar behavioral & physiological S/S in neonate → Withdrawal
symptoms vary upon age neonate, drug/drug’s half-life, & time mother’s last used

DRUG WITHDRAWAL FOR NEONATE

DRUG ONSET OF WITHDRAWAL SYMPTOMS SYMPTOMS OF WITHDRAWAL
Opioids 24.72 rs. - Hyperirritability / Tremors /High-pitched cry
- Nasal congestion
- Hyperthermia
- Tachycardia
- Poor feeding/Regurgitation / Diarrhea

Alcohol 3.12 rs. - Jitteriness/ Irritability / Diaphoresis

- Hypertonia
- Hyperreflexia
- Seizures
- Poor suck
- Poor sleep/ Hyperactivity
- Tremor
 Cocaine 2.3 days - Irritability /Hyperactivity / Tremors
- High-pitched cry
- Some neonates have no symptoms of
withdrawal

Marijuan Depends upon mother’s last use (symptoms may occur if - Hypoglycemia
a mother used marijuana heavily during pregnancy & - Jitteriness/Tremor
during labor) - Exaggerated startle reflex
- Disturbed sleep cycles
Selective 1-14 days - Irritability
serotonin - Tremors
- Excessive crying & Restlessness
reuptake - Increased muscle tone
inhibitors - V&D
(SSRIs)
Caffeine At birth - Jitteriness
- Vomiting
- Tachypnea or Bradycardia

 Neonatal abstinence scales evaluate NB reflexes & behaviors that indicate severity of withdrawal
 Medical management (NAS)
o Transferring infant w/ signs to NICU
o Provide IV fluids to prevent dehydration from N&V
o Provide pharmacological therapy to reduce symptoms & gradually wean NB from substance
o Adm. phenobarbital, effective in controlling seizures
 Avoid naloxone (Narcan) at time of delivery if mother is suspected to be opioid dependent d/t causing abrupt withdrawal &
seizure for NB → morphine used if mom opioid dependent
 Interventions
o Assess daily for signs of withdrawal & reporting S/S immediately
o Adm. & monitor pharmacological Tx.
o Monitoring for skin breakdown & applying barrier ointments for prevention of diaper rash from diarrhea
o Bottle feeding w/ high-calorie formula to promote weight gain OR encouraging breastfeeding, if not contraindicated
o Provide parent education to caretakers of infant
o Communicating w/ & providing a referral to a social worker for post-discharge care & follow-up
o Provide a calm/quiet environment. & Limit stimuli such as stroking, direct speech, and strong fragrances
o Swaddling is usually calming for NB BUT Provide “space” by positioning baby to face outward, away from
caregiver’s body
o Avoid unnecessary handling.
o Use light dimmer to keep lights low.
o Respond quickly to cries.
 Long-term effects r/t prenatal drug exposure
o Poor growth through childhood
o Impaired cognition (learning disabilities) or ADHD
o Poor language development
o Higher rates of criminal behavior & substance abuse disorder
CARE OF THE FAMILY OF AN AT-RISK NEWBORN
 Emotions parents may experience
o Fear of unknown & environment of NICU
o Anger/ guilt that birth experience was not what was planned & mother often blames herself
o Loss of bonding/attachment time b/c parents & child are separated
o Loss of control & frustration b/c the staff does not always communicate openly w/ parents & other women on PP unit have
their babies in their rm
o Anxiety about baby’s health
o Helplessness b/c baby needs high-level skilled care & parents cannot provide care to their infant
 Nursing interventions
o Providing opportunities for parents to hold & bond w/ baby
o Develop therapeutic relationship w/ parents & Never behaving as if the parents are in the way or interrupting
o Providing positive reinforcement for concerns the parents demonstrate & Encouraging parents to talk about NICU experience
o Answering all questions honestly
o Include parents in an open dialogue w/ entire NICU team
o Demonstrating care for parents & baby
o Referring to the baby by his/her first name
o Allowing the parents to provide care → as bathing and feedings
o Allows skin to skin time whenever possible to promote temp. control, glucose stabilization, & bonding