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• Nursing Care of the Newborn With Special Needs and Newborn at Risk is covered in Chapters 23 and 24.

Objectives for Care of Newborns with Special Needs:

• Identify birth weight variations and associated issues.
• Discuss preterm and postterm infants' characteristics and medical management.
• Discuss respiratory distress syndrome and its treatment.
• Describe risk factors for infants of diabetic mothers and their transition (hypoglycemia).
• Discuss pathologic vs. physiologic jaundice and treatment guidelines.
• Summarize assessment and care for newborns with soft tissue, skeletal, and neurologic injuries from birth trauma.
• Identify maternal conditions that place newborns at risk for infection and describe infection identification methods.
• Identify clinical manifestations of infection in newborns.
• Describe the nurse's role in diagnosing neonatal sepsis.
• Identify the effects of maternal alcohol, drug, and tobacco use on fetuses and newborns.
• Understand the needs of infants with meconium aspiration syndrome.

Birth Weight Variations

• Fetal growth is affected by maternal nutrition, genetics, placental function, and environmental factors.
• Birth weight variations include AGA, SGA, and LGA.
• AGA: Average for gestational age.
• SGA: Small for gestational age.
• LGA: Large for gestational age.

SGA Newborns

• SGA newborns weigh <2,500 g (5 lb 8 oz) at term or below the 10th percentile.
• Symptoms include a disproportionately large head compared to body. Other symptoms are:
• Wasted appearance of extremities; loose dry skin.
• Reduced subcutaneous fat stores.
• Decreased breast tissue amount.
• Scaphoid abdomen (sunken appearance).
• Wide skull sutures and poor muscle tone over buttocks and cheeks.
• Thin umbilical cord.
• Common problems are:
• Perinatal asphyxia
• Difficulty with thermoregulation
• Hypoglycemia
• Hyperbilirubinemia
• Birth trauma
• Nursing management requires:
• Weight, length, and head circumference measurements.
• Serial blood glucose monitoring and vital sign monitoring.
• Early and frequent oral feedings, with possible IV dextrose 10%.
• Monitoring for polycythemia signs and symptoms.
• Anticipatory guidance.

LGA Newborns

• LGA newborns weigh >90th percentile on a growth chart or >4,000 g (8 lb 13 oz) at term.
• Assessment includes a large body and plump, full face with a proportional increase in body size.
• Symptoms include:
• Poor motor skills
• Difficulty regulating behavioral states.
• Risk factors include:
• Maternal diabetes mellitus
• Maternal obesity
• Multiparity and prior history of a macrosomic infant
• Male fetus
• Post-dates gestation and genetics.
• Common problems are:
• Birth trauma
• Hypoglycemia
• Hyperbilirubinemia
• Asphyxia.
• Nursing management includes:
• Vital sign monitoring
• Blood glucose level monitoring
• Oral feedings initiated with IV glucose supplementation as needed.
• Monitoring for polycythemia and hypoglycemia signs and symptoms.
• Hydration and phototherapy for high bilirubin levels.

Gestational Age Variations

• Knowledge of newborn's gestational age impacts postnatal management.
• Preterm and postterm infants need special care due to high risk.
• Gestational age variations:
• Postterm: Born after 42 weeks.
• Preterm: Born before 37 weeks.
• Late Preterm: Born between 34+0 and 36+6 weeks.

Postterm Newborn

• Postterm newborns are affected by the placenta's inability to provide oxygen and nutrients after 42 weeks.
• This leads to progressive placental dysfunction, fetal/neonatal mortality increase, and fetal distress during labor.
• Symptoms:
• Dry, cracked, wrinkled skin, meconium stained skin.
• Long, thin extremities with long nails.
• Wide-eyed, alert expression, abundant scalp hair, thin umbilical cord, and limited vernix and lanugo.
• Common problems:
• Perinatal asphyxia
• Hypoglycemia
• Hypothermia
• Polycythemia
• Meconium aspiration
• Nursing Management:
• Resuscitation
• Blood glucose level monitoring
• Feedings initiation with IV dextrose 10%
• Prevention of heat loss
• Polycythemia evaluation
• Parental support

Preterm Newborn

• Prematurity accounts for the largest number of admissions to NICUs.
• Prematurity and LBW are the 2nd leading cause of US infant deaths.
• Organ system immaturity causes risk for many neonatal complications.
• Nursing Assessment:
• Weight <5.5 lb
• Scrawny appearance and poor muscle tone
• Minimal subcutaneous fat and undescended testes
• Plentiful Lanugo
• Poorly formed ear pinna
• Soft spongy skull bones and matted scalp hair
• Absent to few creases in soles and palms
• Minimal scrotal rugae; prominent labia and clitoris
• Thin transparent skin and abundant vernix
• Fused eyelids
• Common problems:
• Hypothermia
• Hypoglycemia
• Hyperbilirubinemia and other issues.
• Nursing Management:
• Oxygenation and thermal regulation.
• Nutrition and fluid balance.
• Infection prevention and stimulation with pain management.
• Growth and development encouragement.
• Parental support who are at high-risk and possible perinatal loss.
• Discharge preparation

Late Preterm Births

• Late preterm infants are born between 34 and 36+7 weeks.
• Elective repeat cesarean sections/inductions
• Morbidities similar to preterm infants:
• Respiratory distress (RDS)
• Hypoglycemia and temperature instability
• Poor feeding and jaundice
• Likely of discharge delays due to illness

Select Acquired Conditions of Newborn

• Neonatal asphyxia, respiratory distress syndrome, meconium aspiration.
• Hyperbilirubinemia and newborn infections.
• Infants of diabetic mothers and birth trauma.
• Newborns of perinatal substance abusing mothers.

Neonatal Asphyxia

• Failure to establish adequate respirations after birth.
• Pathophysiology: insufficient oxygen delivery to meet metabolic demands.
• Nursing assessment involves:
• Assessment of risk factors, newborn’s color, work of breathing, heart rate, temperature, Apgar scores
• Nursing management involves:
• Immediate resuscitation and continued observation.
• Also: neutral thermal environment, blood glucose levels maintenance, and parental support and education.

Respiratory Distress Syndrome

• Lung immaturity and lack of alveolar surfactant are major contributing factors.
• Risk factors include prematurity, male gender, perinatal asphyxia, cold stress, and maternal diabetes.
• Nursing Assessment:
• Expiratory grunting.
• Nasal flaring
• Chest wall retractions
• Tachypnea (rates >60)
• Generalized cyanosis
• Heart rate >150 to 180
• Fine inspiratory crackles
• Nursing Management:
• Supportive care and close monitoring.
• Respiratory modalities such as: ventilation, HFNC, CPAP, PEEP.
• Exogenous surfactant; oxygen therapy.
• Antibiotics for positive cultures.
• Correction of metabolic acidosis.
• Fluids and vasopressors; gavage, IV feedings, and blood glucose level monitoring.
• Clustering of care; prone or side-lying position, and parental support and education.

Meconium Aspiration Syndrome

• Inhalation of particulate meconium mixed with amniotic fluid is secondary to hypoxic stress.
• Differentiate terminal meconium fluid from meconium-stained fluid.
• Risk Factors:
• Placental insufficiency, maternal hypertension, umbilical cord compression and oligohydramnios.
• Maternal drug abuse.
• Symptoms in Nursing Assessment:
• Staining of amniotic fluid, nails, skin, or umbilical cord.
• Barrel-shaped chest; prolonged tachypnea, increasing respiratory distress; intercostal retractions, end-expiratory grunting, cyanosis.

Meconium Aspiration Syndrome: Nursing Management

• Suctioning at birth and maintaining adequate tissue perfusion.
• Decreasing oxygen demand and energy expenditure.
• Maintain neutral thermal environment
• Giving parental support and education

Infants of Diabetic Mothers

• High levels of maternal glucose crossing the placenta, stimulating increased fetal insulin production leads to somatic fetal growth.
• Nursing Assessment:
• Full rosy cheeks and ruddy skin color.
• Short neck and buffalo hump, along with massive shoulders and Distended upper abdomen.
• Excessive subcutaneous fat tissue.
• Symptoms include:
• Hypoglycemia, hypocalcemia, hypomagnesemia, polycythemia, hyperbilirubinemia.
• Most important management: careful monitoring of serum glucose levels.
• Prevention of hypoglycemia and supportive therapy with oxygen, intravenous IV line, and monitoring.
• Support the maintenance of fluid and electrolyte balance (calcium level monitoring, fluid therapy, bilirubin level monitoring).
• Offer parental support and education.

Hypoglycemia in the Newborn

• Plasma glucose levels less than 40 mg/dL.
• Most common metabolic disorder in the newborn, risk factors include:
• LGA, SGA, IDM
• Nursing Assessment:
• Hypotonia, lethargy, and jitteriness with poor feeding.
• Cyanosis and apnea, hypothermia, and seizures.
• Nursing Management:
• Early feeding via breast feeding or formula is important.
• Supportive therapy includes oxygen, intravenous IV line, and monitoring.

Birth Trauma

• Injuries result from the forces of labor and birth.
• Types include fractures, brachial plexus injury, cranial nerve trauma, head trauma, cephalhematoma, caput succedaneum, forceps, or vacuum trauma.
• Nursing Assessment finds bruising, bumps, swelling, and paralysis.
• Check symmetry of structure and function.
• Nursing Management should be primarily supportive, focusing on assessing trauma resolution.
• Monitor for complications like hyperbilirubinemia/jaundice.

Hyperbilirubinemia

• Imbalance in bilirubin production/elimination; total serum bilirubin level >5 mg/dL.
• Pathologic jaundice occurs within the first 24 hours of life.
• Often caused by Rh isoimmunization or ABO incompatibility; needs phototherapy or exchange transfusion.
• Physiologic jaundice:
• Occurs after the first 24 hours of life, usually around Day 2-3.
• Usually due to the immature liver's inability to process excess old red blood cells.
• Often resolves by itself.
• Nursing Assessment:
• Jaundice-yellowing of skin or eyes. Check for signs of Rh incompatibility and bilirubin levels.
• Nursing Management aims toward reduction of bilirubin levels through early feeding and elimination.
• Can be assisted with phototherapy and exchange transfusions.

Newborn Infections

• Neonatal sepsis is caused by bacterial, fungal, or viral microorganisms or their toxins in blood/tissues.
• Sepsis is a significant cause of neonatal morbidity and mortality.
• IgA and IgM require time to reach optimum levels after birth.
• Early-onset or congenital sepsis:
• Manifests within 24-48 hours after birth; acquired in the perinatal period.
• GBS is a common causative agent.
• Late-onset sepsis: occurs ~7-30 days old; is an infection acquired in the hospital or community.
• Nursing Assessment:
• Hypothermia, respiratory distress, and lethargy.
• Nonspecific symptoms and elevated C-reactive protein.
• “Left shift” and positive cultures.
• Nursing Management:
• Antibiotic therapy and circulatory, respiratory, nutritional, and developmental support
• Educate on prevention and Early recognition, and to provide primary disease prevention and family education.

Newborns of Substance-Abusing Mothers

• Common substances are tobacco, alcohol, and marijuana.
• Fetal alcohol syndrome: physical and mental disorders appear at birth + remain problematic throughout life.
• Features associated with Fetal alcohol syndrome:
• Fetal alcohol spectrum disorders and alcohol-related birth defects.
• Neonatal abstinence syndrome: drug dependency acquired in utero manifests via neurologic/physical behaviors.
• Nursing Assessment
  • Get maternal history about risk behaviors and toxicology.
  • Assess the Newborn behaviors like instances of WITHDRAWAL.
• Nursing Management focuses on stimuli reduction/comfort promotion.
• Also focus on nutrition, prevention of complications with encouraging parent-newborn interaction