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Questions and Answers
What is the gestational age cutoff that classifies an infant as preterm?
Which statement accurately reflects the classification of term infants?
What does the Ballard scoring system primarily assess in newborns?
Which infant classification would be considered high-risk according to the information provided?
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What is the weight classification that defines a low birth weight (LBW) infant?
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Which physical characteristic of a preterm infant involves the visibility of superficial veins?
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What is the primary method for determining the gestational age of an infant?
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What factor may contribute to the prematurity of an infant related to maternal health?
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Which statement best describes the importance of early parental interaction with a preterm infant?
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Which of the following is NOT a predisposing cause of premature birth?
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What is the primary cause of respiratory distress syndrome (RDS) in newborns?
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Which method is NOT used for administering supplemental oxygen to infants?
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What is the purpose of monitoring pulse oximetry in preterm infants?
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What condition is characterized by the cessation of breathing for 20 seconds or longer in infants?
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What is a common method for stimulating breathing in preterm infants?
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What is the primary reason why preterm infants are at an increased risk of hypoglycemia?
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Which nursing intervention is crucial for monitoring a preterm infant's body temperature?
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What risk factors contribute to the development of hypocalcemia in preterm infants?
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Which statement accurately describes retinopathy of prematurity (ROP)?
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Why is it important to use intravenous calcium gluconate in treating hypocalcemia in preterm infants?
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What is the recommended birth weight range for infants to have routine retinal exams in the NICU?
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What is a common sign of necrotizing enterocolitis (NEC) in preterm infants?
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What should the urine output for preterm infants be documented as?
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What treatment option is mentioned for preventing blindness in infants with retinal issues?
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What is a significant risk factor for jaundice in preterm infants?
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Why is orogavage preferred over nasal gavage feedings in newborns?
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What level of bilirubin requires careful investigation in preterm infants?
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What is the main benefit of kangaroo care for infants?
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Which method of feeding is typically used for infants younger than 34 weeks of gestation?
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Which sign should be reported regarding the fontanelles of a preterm infant?
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What is the advised positioning for a preterm newborn in the NICU?
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What care should be taken to ensure skin integrity for preterm infants?
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What is a potential consequence of inadequate infant suckling in breastfed infants?
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What is the recommended action for a breastfed infant experiencing late onset jaundice?
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Which of the following is a goal of treatment for hyperbilirubinemia?
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What is the initial nursing response when an apnea monitor alarm sounds for a preterm infant who is stable?
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At what blood glucose level should a preterm infant's glucose be at minimum?
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What nursing care practice is essential for monitoring hyperbilirubinemia in infants?
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What technique can provide warmth and bonding for a preterm infant?
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What should be monitored to observe jaundice progression in an infant?
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What is a common practice during the delivery of a preterm newborn?
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During transport, what type of incubator is often used for preterm infants?
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Study Notes
Preterm Newborn
- Preterm newborns are also known as premature.
- Prematurity and low birth weight are correlated to increased neonatal morbidity.
- The emphasis used to be on birth weight, the focus is now on gestational age and development level.
- Gestational age is the time from conception to birth that the fetus is in the uterus.
- Preterm infant - less than 37 weeks
- Early term infant - between 37 weeks and 38 weeks, 6 days
- Full-term infant - between 39 and 40 weeks, 6 days
- Late-term infant - between 41 weeks and 41 weeks, 6 days
- Postterm infant - beyond 42 weeks
- Infants in all these categories, newly defined by the World Health Organization (WHO), are considered high-risk newborns, regardless of birth weight.
- Low birth weight (LBW) infant is <2500 grams (5.8 lb).
- Infants may have a low birth weight due to intrauterine growth restriction (IUGR), or they may just be small for gestational age (SGA).
- Both are treated as high-risk newborns.
- The less the baby weighs at birth, the greater the risks to life during delivery and immediately afterwards.
- Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA).
- The Ballard scoring system is a standardized method used to estimate gestational age within 1-2 weeks, based on the neonate’s neuromuscular maturity (A) and physical maturity (B).
Causes of Prematurity
- Causes are numerous; in many instances, the cause is unknown.
- Prematurity may be caused by multiple births, illness of the mother, or the hazards of pregnancy itself, such as gestational hypertension, placental abnormalities, and premature separation of the placenta.
- Prematurity is also correlated with poverty, smoking, alcohol consumption, and drug use.
Respiratory Function of the Preterm Newborn
- Important structural changes occur in the fetal lungs during the second half of pregnancy.
- Failure of these changes to occur leads to many deaths attributed to previability.
- Oxygen may be required and can be administered via nasal catheter, incubator, or oxygen hood.
- The oxygen must be warmed and humidified to prevent drying of the mucous membranes.
- Mechanical ventilation may be required.
- Oxygen saturation levels should be monitored.
- The infant is usually admitted to the NICU.
Respiratory Distress Syndrome (RDS)
- RDS type 1 is a result of lung immaturity, which leads to reduced gas exchange.
- An estimated 30% of all neonatal deaths result from RDS or its complications
- This disease is a result of deficient synthesis or release of surfactant, a chemical in the lungs.
- Surfactant is high in lecithin, a fatty protein necessary for the absorption of oxygen by the lungs.
- Testing for the lecithin/sphingomyelin (L/S) ratio provides information about the amount of surfactant in amniotic fluid.
- The symptoms of respiratory distress are apparent after delivery, but they may not manifest for several hours.
- Respirations increase to 60 breaths/min or more.
- Rapid respirations (tachypnea) are accompanied by gruntlike sounds, nasal flaring, cyanosis, and intercostal and sternal retractions.
- Edema, lassitude, and apnea occur as the condition becomes more severe.
- Mechanical ventilation may be necessary.
- Surfactant begins to appear in the fetal alveoli at approximately 24 weeks of gestation and is adequate for the infant to breathe adequately at birth by 34 weeks of gestation.
- It is possible to increase surfactant production by giving the mother injections of corticosteroids, such as betamethasone.
- Surfactant can be administered via endotracheal (ET) tube at birth or when symptoms of RDS occur.
- Surfactant production is altered during episodes of cold stress or hypoxia and when there is poor tissue perfusion.
Nursing Care
- Vital signs are monitored closely, arterial blood gases are analyzed, and the infant is placed in a warm incubator with gentle and minimal handling to conserve energy.
- The concept of cluster care involves combining and coordinating the handling required for assessment and treatments.
- Intravenous fluids are prescribed, and the nurse observes for signs of overhydration or dehydration.
- Oxygen therapy may be given via hood or ventilator in concentrations necessary to maintain adequate tissue perfusion.
- Oxygen toxicity is a high risk for infants receiving prolonged treatment with high concentrations of oxygen.
- Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy.
- Atelectasis, edema, and thickening of the membranes of the lung interfere with ventilation.
- This often results in prolonged dependence on supplemental oxygen and ventilators and has long-term complications.
Apnea
- Apnea is defined as the cessation of breathing for 20 seconds or longer.
- Apneic episodes are accompanied by bradycardia (HR < 110) and cyanosis
- Gentle rubbing of the infant’s feet and back may stimulate breathing.
- Suctioning of the nose and mouth and raising of the infant’s head to a semi-fowler’s position can facilitate breathing.
Neonatal Hypoxia
- Pulse Oximetry level of 92% or greater is normal and should be monitored closely.
- Severely anemic infants or infants with abnormal RBCs may have severe hypoxia and not present with cyanosis.
- Pulse oximetry must be placed properly to get an accurate reading.
Sepsis
- Preterm newborns are at risk for developing sepsis.
- The liver of the preterm infant is immature and forms antibodies poorly.
- Body enzymes are inefficient because of the abbreviated stay in the uterus.
- There is little or no immunity received from the mother, and stores of nutrients, vitamins, and iron are insufficient.
- There may be no local signs of infection, which also hinders diagnosis.
- Signs of sepsis include a low temperature, lethargy or irritability, poor feeding, and respiratory distress.
- Treatment involves administration of intravenous antimicrobials, maintenance of warmth and nutrition, and close monitoring of vital signs, including blood pressure.
- An incubator separates the infant from other infants in the unit and facilitates close observation.
Body Temperature Control
- The preterm infant has a lack of brown fat, which is the body’s insulation.
- There is excessive heat loss by radiation from a surface area that is large in proportion to body weight.
- The large surface area of the head predisposes the infant to heat loss.
- The heat-regulating center of the brain is immature.
- The sweat glands are not functioning to capacity.
- The preterm infant is inactive, has muscles that are weak and are less resistant to cold, and cannot shiver.
- The posture of the preterm infant’s extremities is one of leg extension.
- Metabolism is high, and the preterm infant is prone to low blood glucose levels (hypoglycemia).
Nursing Care
- The infant’s skin temperature will decrease before the core temperature falls.
- A skin probe is used to monitor the temperature of preterm infants.
- The infant is placed under a radiant warmer or in an incubator to maintain a warm environment.
Hypoglycemia and Hypocalcemia
- Hypoglycemia (hypo, “less than,” and glycemia, “sugar in the blood”) is common among preterm infants.
- They have not remained in the uterus long enough to acquire sufficient stores of glycogen and fat.
- The condition is aggravated by the need for increased glycogen in the brain, the heart, and other tissues as a result of asphyxia, sepsis, RDS, unstable body temperature.
- Plasma glucose levels lower than 40 mg/dL in a term infant and lower than 30 mg/dL in a preterm infant indicate hypoglycemia.
- The brain needs a steady supply of glucose, and hypoglycemia must be anticipated and treated promptly.
- Preterm infants may be too weak to suck and swallow formula and often require gavage or parenteral feedings to supply their need of 120 to 150 kcal/kg/day.
- Hypocalcemia (hypo, “below,” and calcemia, “calcium in the blood”) is also seen in preterm and sick newborns.
- Calcium is transported across the placenta throughout pregnancy, but in greater amounts during the third trimester.
- Early birth can result in infants with lower serum calcium levels.
- Infants stressed by hypoxia or birth trauma or who are receiving sodium bicarbonate are at high risk for this problem.
- Infants born to mothers who are diabetic or who have had a low vitamin D intake are also at risk for developing early hypocalcemia.
- Late hypocalcemia usually occurs about age 1 week in newborn or preterm infants who are fed cow’s milk.
- Administering intravenous calcium gluconate is the treatment for hypocalcemia.
- Adding calcium lactate powder to the formula also lowers phosphate levels.
- Calcium lactate tablets are insoluble in milk and must not be used.
Increased Tendency to Bleed
- Preterm infants are more prone to bleeding than full-term infants because their blood is deficient in prothrombin, a factor of the clotting mechanism.
- Fragile capillaries of the head are particularly susceptible to injury during delivery, causing intracranial hemorrhage.
- Ultrasonography is helpful in detecting this problem.
- The nurse should monitor the neurological status of the infant and report bulging fontanelles, lethargy, poor feeding, and seizures.
Retinopathy of Prematurity
- Retinopathy of prematurity (ROP) is a disorder of the developing retina in premature infants that can lead to blindness.
- The condition was formerly termed retrolental fibroplasia, but the term ROP is currently used because it is more precise.
- It is the leading cause of blindness in newborns weighing less than 1500 g (3.3 lb).
- The condition can be caused by many factors, but premature infants are more commonly at risk because their immature retinas are incompletely vascularized at birth.
- After birth, often accompanied by high levels of oxygen required for the infant’s survival, the retina completes an abnormal vascularization process that causes fibrous tissue to form behind the lens of each eye, resulting in blindness and retinal detachment.
Retinopathy of Prematurity (ROP)
- Infants with fully developed vascular systems in the retina at birth are usually not affected by ROP
- Infants with an unstable course should be monitored for ROP
- The American Academy of Pediatrics (AAP) standards recommend routine retinal exams by certified ophthalmologists in the NICU for infants with a birth weight between 1500 and 2000 g or a gestational age less than 30 weeks
- Examination at 4 weeks of age and at proper intervals for follow-up can result in early detection and prompt treatment
- Retinal ablative therapy using laser photocoagulation or intravitreal injection of bevacizumab has been used with success in preventing blindness
- Follow-up for other eye problems, such as strabismus, refractive errors, or cataracts, should be provided within 4 to 6 months after discharge from the NICU
Preterm Infant Nutrition
- The preterm infant's stomach capacity is small
- Sphincter muscles at both ends of the stomach are immature, which contributes to regurgitation and vomiting
- Sucking and swallowing reflexes are immature
- The infant's ability to absorb fats is poor (including fat-soluble vitamins)
- Parenteral or orogavage feedings are usually required
- Orogavage is preferred to nasal gavage feedings because newborns are obligatory nose breathers
- Abdominal girth should be measured and bowel sounds assessed to detect early signs of necrotizing enterocolitis
- Signs that indicate readiness for oral feeding include a strong gag reflex and sucking and rooting reflexes
- Nipple feedings are started slowly, and some initial weight loss may be noted.
- Placing the infant on the right side or abdomen after feeding promotes gastric emptying and reduces aspiration if vomiting occurs
Necrotizing Enterocolitis (NEC)
- An acute inflammation of the bowel that leads to bowel necrosis
- Factors implicated include a diminished blood supply to the lining of the bowel wall because of hypoxia or sepsis, which causes a decrease in protective mucus and results in bacterial invasion
- A source for bacterial growth occurs when the infant is fed a milk formula or hypertonic gavage feeding
- Signs of NEC include abdominal distention, bloody stools, diarrhea, and bilious vomitus
- Specific nursing responsibilities include observing vital signs, maintaining infection control techniques, and carefully resuming oral fluids as ordered.
- Treatment includes antimicrobials and the use of parenteral nutrition to rest the bowels
- Surgical removal of the necrosed bowel may be indicated
Immature Kidneys
- Improper elimination of body wastes contributes to electrolyte imbalance and disturbed acid-base relationships
- Dehydration occurs easily
- Tolerance to salt is limited, and susceptibility to edema is increased
- The nurse should document the intake and output for all preterm infants
- The urine output should be between 1 and 3 mL/kg/hr
- The infant should be observed closely for signs of dehydration or overhydration
Jaundice
- The liver of the newborn is immature, which contributes to a condition called icterus, or jaundice
- Jaundice causes the skin and the whites of the eyes to assume a yellow-orange cast.
- The liver is unable to clear the blood of bile pigments that result from the normal postnatal destruction of red blood cells
- The higher the blood bilirubin level is, the deeper the jaundice, and the greater the risk for neurological damage
- An increase of more than 5 mg/dL in 24 hours or a bilirubin level greater than 12.9 mg/dL requires careful investigation
- Pathological jaundice occurs within 24 hours of birth and is secondary to an abnormal condition, such as ABO-Rh incompatibility
- The normal rise in bilirubin levels is slower in preterm infants than in full-term infants and lasts longer, which predisposes the infant to hyperbilirubinemia
- There is more evidence of jaundice in infants who are breastfed
- Breast milk jaundice begins to be seen about the fourth day
- Early onset jaundice of the breastfed infant necessitates an increase in breastfeeding—glucose water feedings should not be offered as they may reduce milk intake and further increase bilirubin levels
- In late onset jaundice of the breastfed infant, breast milk may inhibit conjugation of bilirubin, and therefore formula may be substituted for 24 to 48 hours to reduce bilirubin levels
- The total serum bilirubin level typically peaks 3 to 5 days after birth
Normal Blood Glucose Level for a Preterm Infant
- The normal blood glucose level should be a minimum of 30 mg/dL
Initial Nursing Response for Apnea
- Gently rub the infant’s back
Nursing Goals for the Preterm Newborn
- Improve respiration
- Maintain body heat
- Conserve energy
- Prevent infection
- Provide proper nutrition and hydration
- Give good skin care
- Observe the infant carefully and record observations
- Support and encourage the parents
Thermoregulation
- Incubators provide a neutral thermal environment
- Radiant heat cribs supply overhead heat
- A reflective patch should be placed over the skin temperature probe to ensure the infant's skin temperature reading is not affected by the infrared heat of the radiant warmer
Kangaroo Care
- A method of care for preterm infants that uses skin-to-skin contact to maintain warmth and bonding
- Mother or father (with gown that open in the front) has naked chest contact with the infant (wearing only a diaper and small cap)
- The skin provides warmth and calms the child, and the contact promotes bonding
- Kangaroo care has been shown to be superior to holding a blanket-wrapped infant in enhancing the stabilization of infants and promoting later development
Nutrition
- Feeding varies with gestational age and health status
- Very preterm infants may require gavage feedings
- Infants weighing more than 1500 g may be able to bottle feed
- Human milk is ideal, because the fat is absorbed readily
- Breast milk may be manually expressed by the mother and placed in a bottle for her preterm infant
- The tube is replaced every 3 to 7 days
- Intravenous fluids may be provided to meet fluid, calorie, and electrolyte needs
- Infants are often fed while still in the incubator
- Early initiation of feedings reduces the risk of hypoglycemia, hyperbilirubinemia, and dehydration
- The nurse should observe and record bowel sounds and the passage of meconium
- The nurse should aspirate the contents of the stomach before feeding
- Infants older than 28 weeks of gestation usually have the digestive enzymes required for the digestion of breast milk
- Formulas designed for the term infant are not well tolerated by preterm infants
- Formulas designed for preterm infants are not well tolerated by infants older than 34 weeks of gestation or term infants
- Supplemental vitamins are usually prescribed for the preterm infant
- If the infant is too premature or too ill to tolerate oral feedings, total parenteral nutrition (TPN) may be prescribed
Close Observation
- Observe for:
- General activity: Increase or decrease in movements, lethargy, twitching, frequency and quality of cry, hyperactivity
- Fontanelles: Sunken, flat, or bulging
- Eyes: Discharge
- Respirations: Regularity, apnea, sternal retractions, labored breathing
- Pulse: Rate and regularity
- Abdomen: Distention
- Cord: Discharge, odor
- Feeding: Sucking ability, vomiting or regurgitation, degree of satisfaction
- Voiding: Initial, frequency
- Stools: Frequency, color, consistency
- Mucous membranes: Dryness of lips and mouth, signs of thrush
- Color: Paleness, cyanosis, jaundice
- Skin: Rashes, irritations, pustules, edema
Positioning and Nursing Care
- In the NICU environment, with close observation, the preterm newborn can be positioned on the side or prone, with the head of the mattress slightly elevated unless contraindicated
- Positioning should be compatible with drainage of secretions and the prevention of aspiration
- An enclosed space, or nesting, can provide a calming, supportive environment that promotes body flexion
- Infants should be gradually weaned from the prone position when the physical condition becomes stable, and they should be placed in the supine position well before discharge from the NICU
- Teach the parent about the importance of the “back-to-sleep” concept to prevent SIDS
- The infant should not be left in one position for long periods
- Daily cleansing of the eyes, mouth, and diaper area, and baths two or three times weekly with the application of emollients promotes skin integrity
- Create a quiet environment and organize nursing care so that overstimulation is avoided
- Blankets can be placed over the top of the incubator to reduce external stimulation
- Eye patches can be placed over the infant’s eyes to protect against the bright procedure lights
- The preterm infant should be awakened slowly and gently for procedures or nursing care and should be moved gently, maintaining flexion of the arms close to the midline of the infant’s body
- Nonnutritive sucking is beneficial
Complementary Medicine in the NICU
- Aroma therapy: Placing an article of clothing with the mother’s natural body odor next to the newborn in the incubator
- Music therapy may be effective in calming the infant
- Gentle therapeutic touch and gentle massage reduce motor activity and energy expenditure and enhance bonding with the parents
Ideal Feeding for Most Preterm Newborns
- Breast milk given by suckling, bottle, or gavage
Premature Infant Prognosis
- Very-low-birth-weight infants may not catch up with term infants in growth rate, especially if there has been chronic illness, insufficient nutrient intake, or inadequate caretaking.
- Development of the preterm infant is based on current age minus the number of weeks before term that the infant was born.
Family Reaction to Preterm Infant
- The nurse should assist parents in coping with their responses to having a small, preterm infant.
- Parents may feel disheartened by the preterm infant's appearance.
- Parents may believe they are to blame for the infant's condition.
- Parents may fear the infant will die and be unable to express their feelings.
- The mother may be concerned about her ability to care for such a small and helpless infant.
- Nursing care of the preterm infant includes providing short periods of stimulation during the alert phase of activity.
- Parents can be taught to provide stimulation by using a black and white mobile, stroking gently, talking to the infant, rocking, or providing range-of-motion activity or kangaroo care.
Postterm Newborn Characteristics
- A pregnancy is considered postterm if it lasts longer than 42 weeks.
- The major goal of treatment is to identify infants who are not tolerating the extra time in the uterus.
- Postmaturity refers to the infant showing characteristics of the postmature syndrome.
- The placenta does not function adequately as it ages, which could result in fetal distress.
- The mortality rate of late infants is higher than that of newborns delivered at term.
- Morbidity rates are also higher.
Postterm Newborn Problems
- Asphyxia caused by chronic hypoxia while in the uterus because of a deteriorated placenta.
- Meconium aspiration due to hypoxia and distress that may cause relaxation of the anal sphincter, and meconium can be aspirated into the fetal lungs.
- Poor nutritional status; depleted glycogen reserves cause hypoglycemia.
- Increase in red blood cell production (polycythemia) because of intrauterine hypoxia.
- Difficult delivery because of increased size of the infant.
- Birth defects.
- Seizures as a result of the hypoxic state.
Postterm Newborn Physical Characteristics
- Infant is long and thin, appearing to have lost weight.
- Skin is loose, especially about the thighs and buttocks.
- There is little lanugo (downy hair) or vernix caseosa.
- The nails are long and may be stained with meconium.
- The infant often has a thick head of hair and looks alert.
Postterm Newborn Nursing Care
- Labor induction or cesarean deliveries are commonly performed if testing determines that the pregnancy is past 42 weeks or if there are signs of fetal distress or maternal risk.
- Many postterm infants suffer few adverse effects from the delay but still require careful observation in the nursery.
- Observe for respiratory distress, hypoglycemia, and hyperbilirubinemia.
- The infant may be placed in an incubator because fat stores have been used in utero for nourishment, and the infant is vulnerable to cold stress.
Transporting the High-Risk Newborn
- Transporting the high-risk newborn to a regional neonatal center requires organization and expertise of a special team.
- Stabilization of the infant before discharge is important.
- Baseline data, such as vital signs, glucose level, and blood gases are obtained, and the infant is weighed.
- Copies of all records, including mother’s prenatal history, delivery, and infant records, are required.
- A transport incubator is prepared, and batteries are fully charged.
Nursing Responsibilities for High-Risk Newborn Transport
- Place an identification band on the infant and verifying the ID name and number with the mother’s ID band.
- Provide the name and location of the receiving hospital, and physician name and phone number.
- Allow pictures to be taken or allow the parents to see the infant before transport, as such situations required special empathy.
- Upon arrival, the parents should be contacted by telephone.
Discharge of the High-Risk Newborn
- Discharge planning begins at birth.
- Parents will need to demonstrate and practice routine and specialized care.
- Familiarize them with the newborn’s care.
- Discuss the newborn’s behavioral patterns and realistic expectations concerning the infant’s catch-up development.
- Nurse home visits to assess the home and provide additional support are valuable.
- Stress the need for well-baby examinations, immunizations, and prevention of infection.
- Good prenatal care for subsequent pregnancies because the mother is high-risk for future preterm births.
- Communication is essential.
- Support group referrals are given to parents, and newborn CPR techniques are reviewed.
Kangaroo Care
- Skin-to-skin contact to help with temperature regulation and bonding.
- The infant wears only a diaper and a small cap, rests on the parent’s naked chest.
Discharge Teaching for Families of Infants in the NICU
- Parents must be able to demonstrate and practice routine and specialized care for their infant.
- They must understand their infants' behavioral patterns and have realistic expectations concerning the infant’s catch-up development.
- The family needs to understand the importance of follow-up appointments and other resources.
- They should be provided with information about support groups and local resources.
- The infant should be stable and able to maintain their temperature without assistance.
- The infant must be able to feed effectively either by breast or bottle, and be able to gain weight.
- All of the infant's vital signs should be normal.
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Test your knowledge on neonatal care and classifications with this informative quiz. Questions cover preterm classification, weight criteria, and scoring systems for newborns. Perfect for students and professionals in the field of neonatology.
