NURSING CARE OF THE HIGH-RISK NEWBORN NURSING CARE OF THE HIGH-RISK NEWBORN

MOTHER AND CHILD MOTHER AND CHILD

CARE LECTURE CARE LECTURE
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NURSING CARE OF THE HIGH-RISK NEWBORN MATERNAL & CHILD LECTURE
JILL MONICA DAQUIPIL || BSN-2 || BATCH 2026
 Race (nonwhites have a higher
HIGH-RISK NEWBORN incidence of prematurity than whites)
 Identifies a group of newborns who  Cigarette smoking
very likely will develop a severe acute
disease or an adverse outcome.
 A high-risk neonate can be defined as  Age of the mother (highest incidence is
a newborn, regardless of gestational in mothers younger than age 20 years)
age or birth weight, who has a greater-  Order of birth (early birth is highest in
than-average chance of morbidity or first pregnancies and in those beyond
mortality because of conditions or the fourth pregnancy)
circumstances associated with birth  Closely spaced pregnancies
and the adjustment to extrauterine  Abnormalities of the mother’s
existence. reproductive system, such as
 Any infant who is born dysmature intrauterine septum
(before term or postterm, or who is  Infections (especially urinary tract
underweight or overweight for infections)
gestational age) is also at risk for  Pregnancy complications, such as
complications at birth or in the first premature rupture of membranes or
few days of life. premature separation of the placenta
 Early induction of labor
PROBLEMS RELATED TO MATURITY  Elective cesarean birth
A. PREMATURITY/THE PRETERM INFANT
 A preterm infant is traditionally CAUSES
defined as a live-born infant born  Idiopathic
before the end of 37 weeks of
gestation CLINICAL FEATURES
 Divided in terms of the degree of care Signs of Prematurity: On gross inspection
needed:  Very small
A. Late preterm – born between 34  Head is disproportionately large > 3 cm
and 37 weeks greater than the chest size
B. Early preterm –born between 24  Skin is ruddy- due to lack of
and 34 weeks subcutaneous fat beneath it- veins
easily seen
 Acrocyanosis (bluish color on palms and
RISK FACTORS feet) may be present
 Low socioeconomic level  If delivered > 28 weeks of gestation
 Poor nutritional status covered with vernix caseosa
 Lack of prenatal care  If very preterm infant (28 weeks of
 Multiple pregnancy gestation- vernix caseosa is lacking)
 Previous early birth  Very low gestation- lanugo is scant
  Late preterm babies- lanugo is 4. Scarf sign – taking the baby’s arm and moving
extensive, covering the back, forearms, it across the baby’s chest
forehead and sides of the face  Mature- if there is resistance felt by the
 Anterior and posterior fontanelles will examiner
be small  Premature – if the arm can be wrapped
 Few or no creases on the soles of the around the baby’s chest
feet 5. Heal to ear – bending the knee
 Eyes are small as compared to full term  Mature – there is resistance felt by the
infants examiner
 Neurologic function in the preterm  Premature – if the leg can be brought
infant is often difficult to evaluate all the way to the ear
because the neurologic system is still so
immature. 6. Skin texture
 Observing the infant make spontaneous  Mature – thicken
or provoked muscle movements can be  Premature-sticky and transparent
as important as formal reflex testing.  Post mature-leathery and wrinkled
 If they are tested, reflexes such as 7. Lanugo
sucking and swallowing will be absent if  Mature- very little lanugo
an infant’s age is below 33 weeks; deep  Premature – abundant
tendon reflexes such as the Achilles  Very premature – absent
tendon reflex will also be markedly 8. Plantar creases-found at the bottom of baby’s
diminished. feet
 a preterm infant is much less active  Mature- positive creases on the entire
than a mature infant and rarely cries on sole of the foot
examination  Premature – soles are smooth, no
creases
NEUROMUSCULAR MATURITY 9. Breast tissue
1. Posture  Mature-areola: 5-10 mm in size
 Mature - baby’s arms should be flexed  Premature-areola are not perceptible
or bent in 10. Ear cartilage
 Premature – baby’s arms are extended  Ears:
of flaccid  Mature- if pinna is bended
2. Square window forward, it will recoil back very
 Assess the wrist flexibility of the baby quickly
 Procedure: bend the hand all the way  Premature – if pinna is bended
down until it hits the arm forward, it will stay
 Mature- the examiner must be able to 11.Genitalia
do it without resistance from the baby  For male baby:
 Premature - the examiner cannot bend  Mature – pendulous testicles
the baby’s hand even to 90 degrees and with rugae present and
3. Recoil of extremities little wrinkles on testicles
 Mature -- extremities return briskly to  Premature – scrotum :flat and
full flexion smooth
 Premature -- response is minimal or  For Female baby:
absent full-term infant extremities  Mature- labia majora will
return briskly cover the labia minora and
clitoris
  Premature- prominent clitoris bloodstream from an excessive
and flat labia breakdown of RBC at birth.
 Bilirubin encephalopathy is a rare
COMPLICATIONS neurological condition that occurs in
1. Anemia of Prematurity some newborns with severe jaundice.
 develops a normochromic normocytic  Kernicterus is a condition where very
anemia (normal cells just few in high bilirubin levels in the blood are
number) deposited in the brain tissue causing
 Anemia occurs from a combination of irreversible damage to the brain.
immaturity of the hematopoietic  Bilirubin is toxic to cells of the brain. If
system (the effective production of red a baby has severe jaundice, there's a
cells with an elevated reticulocyte count risk of bilirubin passing into the brain.
may not begin until 32 weeks of
pregnancy) combined with destruction SIGNS
of RBC because of low level of Vit E, a  Listlessness
substance that protects RBC against  Difficulty waking
oxidation.  High-pitched crying
 Poor sucking or feeding
 Signs: pale, lethargic, and anorectic in
appearance MEDICAL MANAGEMENT
 Phototherapy
 Exchange transfusion
MEDICAL MANAGEMENT
 Blood transfusions to supply needed 3. PERSISTENT PATENT DUCTUS ARTERIOSUS
red blood cells and vitamin E and iron.  Preterm infants’ lungs are noncompliant
 DNA recombinant erythropoietin due to lack of surfactant, making it hard
stimulates RBC production but because for the infant to move blood from the
this appears to be associated with an pulmonary artery into the lungs- can
increased incidence of retinopathy of lead to pulmonary artery hypertension
prematurity (ROP), administration of that can interfere to closure of the
this would be a last resort ductus arteriosus.

MEDICAL MANAGEMENT
NURSING MANAGEMENT
 Indomethacin or ibuprofen for term
 Extraction or drawing of blood ==
infant to cause closure of a patent
should be coordinated to the fewest
ductus arteriosus-making ventilation
possible and have a record of the blood
more efficient.
loss for these tallied.
 Delaying cord clamping == to allow a
NURSING MANAGEMENT
little more blood from the placenta to
 Monitor urine output
enter the infant.
 Observe bleeding at injection site, if the
medication is prescribed
2. ACUTE BILIRUBIN ENCEPHALOPATHY (ABE)
 Destruction of brain cells by invasion of
indirect or unconjugated bilirubin –
results from a high concentration of
4. PERIVENTRICULAR/INTRAVENTRICULAR
indirect bilirubin that forms in the
HEMORRHAGE
  Preterm infants are prone to RISK FACTORS
periventricular hemorrhage (bleeding  Primipara
into the tissue surrounding the  Previous postterm pregnancies
ventricles) or intraventricular  advanced maternal age
hemorrhage (bleeding into the  genetics
ventricles) because of fragile capillaries 
and immature cerebral vascular CAUSE
development.  Unknown
 When there is a rapid change in cerebral
blood pressure, such as could occur with
hypoxia, intravenous infusion,
ventilation, or pneumothorax (lung CLINICAL FEATURES
collapse), capillary rupture could occur;  Characteristics of SGA (Small
brain anoxia then occurs distal to the Gestational Age)
rupture.  dry, cracked almost leatherlike
 Development of hydrocephalus == if skin from lack of fluid
there was bleeding into the narrow  Absence of vernix
aqueduct of Sylvius  Fingernails will have grown
 Intraventricular hemorrhage occurs most well beyond the end of the
often in VLBW infants and is classified as: fingertips
Grade 1 bleeding occurred in just a small  Shows more alertness like a 2-
area of one ventricle week-old baby than a newborn
Grade 2 a greater amount of bleeding
occurred and multiple ventricles Complications
may be involved  oligohydramnios
Grade 3 bleeding is so extensive the  polycythemia
ventricles enlarge  perinatal asphyxia
Grade 4 there is bleeding into brain  meconium aspiration
tissue surrounding the ventricles  cerebral palsy
 cognitive and developmental problems

PROGNOSIS: DIAGNOSES
 UTZ== to measure the biparietal
diameter of the fetus
B. POSTMATURITY/POSTTERM INFANT  Nonstress test or biophysical profile==
 A post term infant is one born after the to see if the placenta is still functioning
41st week of pregnancy. well.
 If stayed in the uterus past Week 41,
the fetus is at special risk because the
placenta appears to function effectively WHAT TO EXPECT FROM THE NEWBORN
for only 40 weeks.  Difficulty establishing respirations.
 After this time, the placenta seems to  Polycythemia- due to decreased
lose its ability to carry nutrients oxygenation in the final weeks
effectively to the fetus and the fetus (Polycythemia refers to an increase in
begins to lose weight (post term the number of red blood cells in the
syndrome) body.)
  Increased hematocrit level- due to  5 pounds 11 ounces to 8
polycythemia and dehydration that pounds 6 ounces (2.6 to 3.8
lowered the circulating plasma level. kg)
 Hypoglycemia in the first hour of life  SGA infants: small for their age
due to fetal consumption of stored due to intrauterine growth
glucose for nourishment in the last restrictions (IUGR) or failed to
weeks of intrauterine life grow.
 Subcutaneous fat level is low- due to
usage in utero, leading to hypothermia RISK FACTORS
 Maternal malnutrition
 Preeclampsia
MEDICAL MANAGEMENT  Multiple gestation pregnancies
 Cesarean Birth-if placental functioning
is compromised CAUSES
 Woman’s nutrition during pregnancy
NURSING MANAGEMENT plays a vital role in fetal growth, lack of
 Administer immediate care of the adequate nutrition may be a major
newborn reason to IUGR
 Monitoring blood glucose for  Adolescents – eating only to meet their
hypoglycemia. own nutritional needs
 Allow woman to spend enough time  Chromosomal abnormality – placenta is
with her newborn. supplying the infants needs during
 Follow up care until school age to track intrauterine life but the infant is not
their developmental abilities utilizing it properly
 Common cause: placental
PROGNOSIS: issue/problem: either the placenta did
not obtain sufficient nutrients from the
uterine arteries or inefficient at
transporting nutrients to the fetus
 Women with systemic diseases

PROBLEMS RELATED TO GESTATIONAL

WEIGHT CLINICAL FEATURES
A. THE SMALL FOR GESTATIONAL AGE Inspection of the infant after birth
INFANT  Appearance: below average weight,
 An infant is SGA if the birth weight is length, and head circumference
below the 10th percentile on an  Overall wasted appearance: poor skin
intrauterine growth curve for that age. turgor, with large head because the rest
 Infant may be born: Preterm: before of the body is small.
week 38 of gestation.  Skull sutures widely separated
 Term: between week 38 and  Hair dull and lusterless
42  Small liver- can cause difficulty
 Post term: past 42 weeks regulating glucose, protein and
 Between 18 and 22 inches bilirubin.
(45.7 to 60cm)  Sunken abdomen
 Dry umbilical cord and stained yellow.
  Better neurologic responses  LGA refers to neonatal birth weight
 With sole creases, ear cartilage well larger than 90th percentile for a given
developed. gestational age. In contrast to LGA,
 Alert and active fetal macrosomia is defined as an
absolute birth weight above a specific
LABORATORY FINDINGS threshold regardless of gestational age.
 Blood test: high hematocrit == due to
lack of fluid RISK FACTORS
 Increased RBC (polycythemia) == due  Obesity
to anoxia during intrauterine life which  Diabetes mellitus
stimulated excess development can  Multiparity
lead to increased blood viscosity that
puts extra work on the infant’s heart CAUSES
because it is more difficult to circulate  Overproduction of nutrients and growth
thick blood- acrocyanosis (blue hands hormone in utero
and feet)  Woman is obese.
 If polycythemia is increased== can lead  Woman is diabetic.
to blockage of the blood vessels and  Beckwith–Wiedemann syndrome, a rare
thrombus formation condition characterized by general body
overgrowth and congenital anomalies
MEDICAL MANAGEMENT such as omphalocele, may also be a
 Exchange transfusion is necessary to cause.
dilute the blood.
 IV glucose to sustain blood sugar until CLINICAL FEATURES
the infant can suck well enough to take  Woman’s uterus appears to be
sufficient feedings. unusually large for the date of
pregnancy
NURSING MANAGEMENT  Appearance of the infant upon delivery:
 Provide adequate fluid and electrolytes  Immature reflexes
and nutrition  Low score on gestational age
 Decrease metabolic demands when examination relations to size
possible  May have extensive bruising or
 Prevent hypoglycemia broken clavicle or Erb
 Maintain a neutral thermal Duchenne paralysis from
environment. trauma to the cervical nerves in
 Provide education and emotional order for the shoulders to be
support. born vaginally.
 Capput succedaneum,
B. LARGE FOR GESTATIONAL AGE INFANT cephalohematoma or molding
(MACROSOMIA) due to large head exposing to
 An infant is LGA if the birth weight is more than enough pressure
above the 90th percentile on an during delivery
intrauterine growth chart for that
gestational age.  CARDIOVASCULAR DYSFUNCTION
 Can seemingly healthy upon birth but  polycythemia may occur as
often reveal as immature development. the fetus attempts to
oxygenate more than the
 average amount of body
tissue
 Observe for
hyperbilirubinemia due to
absorption of blood from
bruising and breakdown of the
extra RBC created by
polycythemia
 Assess HR
 If with cyanosis- due to poor
heart

 HYPOGLYCEMIA
 Observe for the first hour of
life because infants who are
too large require large
amounts of nutritional stores
to sustain their weight
 If the mother has diabetes,
the infant might have an
increase glucose level causing
for the infant to produce
elevated levels of insulin

COMPLICATIONS
 Shoulder dystocia

DIAGNOSIS
 Non stress test or biophysical profile ==
to assess if the placenta can sustain a
large fetus
 Amniocentesis == to assess the fetal
lung maturity

MANAGEMENT
 If the fetal size is not detected during
pregnancy, it may be recognized during
labor when the baby appears too large.