Postpartum Nursing Care ELO C: Preterm and Post term Newborns

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Questions and Answers

What is the definition of a preterm newborn?

A newborn born between 39 weeks and 40 weeks, 6 days

A newborn born at less than 37 weeks of gestation (correct)

A newborn with a birth weight of 2500 grams or less

A newborn born after 42 weeks of gestation

Which newborn classification is defined as being born between 37 weeks and 38 weeks, 6 days of gestation?

Late-term infant

Full-term infant

Postterm infant

Early term infant (correct)

What does the Ballard scoring system primarily measure?

Maternal health during pregnancy

The infant's birth weight and length

Gestational age based on physical and neuromuscular maturity (correct)

Infant's heart rate and breathing patterns

Why are all categories of newborns redefined by the WHO considered high-risk?

Regardless of birth weight or gestational age Signup and view all the answers

What is the significance of low birth weight (LBW) in infants?

LBW infants generally have a lower chance of survival Signup and view all the answers

What is the primary method used to determine the gestational age of a newborn infant?

Assessment of physical and neurologic characteristics Signup and view all the answers

Which physical characteristic is commonly observed in preterm newborns?

Short nail length Signup and view all the answers

What is a significant risk associated with preterm infants that may increase the chances of neglect or abuse?

Parents’ lack of preparation for financial strain Signup and view all the answers

Which statement is true regarding the effects of prematurity on infant health?

Maturity of the organs can impact functioning outside of the womb. Signup and view all the answers

Which factor is NOT a known predisposing cause of preterm birth?

Low levels of physical activity in parents Signup and view all the answers

What is a key factor contributing to Respiratory Distress Syndrome (RDS) in preterm infants?

Immaturity of lung function leading to reduced gas exchange Signup and view all the answers

Which of the following treatments is used to address insufficient surfactant in preterm infants?

Injections of corticosteroids to the mother Signup and view all the answers

What physiological response is commonly associated with apnea in preterm infants?

Bradycardia (HR < 110) during episodes Signup and view all the answers

What is considered a normal pulse oximetry level for infants?

92% or greater Signup and view all the answers

Which nursing intervention is most appropriate for promoting respiratory function in an infant experiencing respiratory distress?

Position the infant in a semi-fowler's position Signup and view all the answers

What is a common characteristic of preterm infants that contributes to their susceptibility to cold stress?

Lack of brown fat Signup and view all the answers

What is the optimal temperature range for a preterm infant's body in an incubator?

36.2° to 37.0° C Signup and view all the answers

Which condition is indicated by plasma glucose levels lower than 30 mg/dL in a preterm infant?

Hypoglycemia Signup and view all the answers

What complication arises due to the immature retinas of premature infants?

Retinopathy of Prematurity Signup and view all the answers

How frequently should the glucose levels of a preterm infant be monitored?

As per standard protocol Signup and view all the answers

What is the primary treatment for early hypocalcemia in a preterm infant?

Intravenous calcium gluconate Signup and view all the answers

Why are preterm infants at a higher risk for intracranial hemorrhage?

Their blood is deficient in prothrombin Signup and view all the answers

What is the primary cause of early onset jaundice in breastfed infants?

Inadequate suckling at the breast Signup and view all the answers

What should be avoided to prevent worsening jaundice in breastfed infants?

Supplemental glucose water feedings Signup and view all the answers

When may formula be used to address late onset jaundice in breastfed infants?

For 24 to 48 hours Signup and view all the answers

What is a critical goal in the treatment of hyperbilirubinemia?

Prevent kernicterus Signup and view all the answers

What is the most appropriate initial response when an apnea monitor alarm goes off for a preterm infant?

Gently rub the infant's back Signup and view all the answers

What is the minimum acceptable blood glucose level for a preterm infant?

30 mg/dL Signup and view all the answers

What is a key nursing goal for the care of preterm infants regarding body temperature?

Maintain a stable body temperature Signup and view all the answers

What is an appropriate care practice for preterm infants in order to provide warmth and bonding?

Use Kangaroo Care method Signup and view all the answers

Which factor is most critical for monitoring jaundice progression in infants?

Color changes in the infant's skin Signup and view all the answers

What is the recommended action for infants with a birth weight between 1500 and 2000 g or a gestational age less than 30 weeks?

Routine retinal exams by certified ophthalmologists Signup and view all the answers

Which intervention can help prevent blindness in high-risk infants?

Laser photocoagulation or intravitreal injection of bevacizumab Signup and view all the answers

What should be assessed in preterm infants to detect early signs of necrotizing enterocolitis (NEC)?

Abdominal girth and bowel sounds Signup and view all the answers

What condition does immature kidney function in preterm infants contribute to?

Altered electrolyte balance and dehydration Signup and view all the answers

What is a common sign of necrotizing enterocolitis (NEC) in preterm infants?

Abdominal distention and bloody stools Signup and view all the answers

Which statement about jaundice in newborns is correct?

The risk of neurological damage increases with elevated bilirubin levels. Signup and view all the answers

What technique is preferred over nasal gavage feedings for preterm infants and why?

Orogavage; it does not obstruct nasal breathing. Signup and view all the answers

Which of the following statements reflects the understanding of oxygen therapy in high-risk infants?

Maintaining adequate oxygen levels is essential to prevent neurological damage. Signup and view all the answers

What is the purpose of documenting intake and output in preterm infants?

To track fluid balance and signs of dehydration. Signup and view all the answers

Study Notes

The Preterm Newborn

Preterm newborns are also known as premature infants and are patients commonly admitted to NICUs.
Prematurity and low birth weight are associated with increased neonatal morbidity.
The emphasis has shifted towards gestatational age instead of just birth weight for classifying newborns.
Gestational age is defined as the time from conception to birth.
Infants born before 37 weeks are preterm, those born between 37-38 weeks, 6 days are early term, and those born between 39-40 weeks, 6 days are full term.
Infants born between 41-41 weeks, 6 days are late term and those born beyond 42 weeks are post term.
All of these categories are considered high-risk newborns despite birth weight.
Low birth weight (LBW) is defined as an infant weighing 2500 grams (5.8 lb) or less.
An infant may have a low birth weight due to intrauterine growth restriction (IUGR) or be small for gestational age (SGA), both are treated as high-risk newborns.
Infants with lower birth weights are at higher risk during delivery and immediately afterward.
The Ballard scoring system is a standardized method used to estimate gestational age within 1-2 weeks.
The Ballard scale assesses neuromuscular maturity (A) and physical maturity (B) of a newborn.
A newborn will score 45 for a 42-week gestation and 20 for a 32-week gestation.
An accurate assessment of a newborn’s maturity aids in personalized care plans.
Factors contributing to prematurity include: multiple births, maternal illness like malnutrition, heart disease, diabetes mellitus, or infectious conditions, hazards of pregnancy like gestational hypertension, placental abnormalities, placenta previa, and premature separation of the placenta.
Other factors like poverty, smoking, alcohol consumption, and drug abuse are also linked to prematurity.
Adequate prenatal care is crucial for preventing preterm birth.
Families with preterm infants may face additional financial and emotional strain.
Early parental interaction with the preterm infant is vital for bonding and attachment.
Multidisciplinary care, including parent aides and other types of home support and assistance, is crucial, especially because current studies indicate a correlation between high-risk births and child abuse and neglect.

Inadequate respiratory function is a common problem among preterm newborns.
Structural changes in fetal lungs occur during the second half of pregnancy, enhancing oxygen absorption.
Preterm newborns may have underdeveloped respiratory muscles, abdominal distention causing pressure on the diaphragm, immature respiratory centers, and weak gag and cough reflexes.
Oxygen therapy may be required, which needs to be warmed and humidified to prevent mucous membrane drying.
Mechanical ventilation can be necessary for preterm infants.
Oxygen saturation levels need to be constantly monitored.
Respiratory distress syndrome (RDS), also known as hyaline membrane disease, is a severe condition caused by lung immaturity.
An estimated 30% of neonatal deaths result from RDS or its complications.
RDS develops due to deficient surfactant production, which is essential for lung oxygen absorption.
Testing for the lecithin/sphingomyelin (L/S) ratio can determine surfactant levels in amniotic fluid.
Symptoms of respiratory distress usually manifest after birth, but may take several hours.
RDS symptoms include increased respiration, gruntlike sounds, nasal flaring, cyanosis, and retractions.
Mechanical ventilation may be required for treating severe RDS.
Surfactant production can be increased through administering corticosteroids to the mother before delivery.
For preterm newborns, surfactant can be administered via an endotracheal (ET) tube at birth or when RDS symptoms appear.
Surfactant production can be affected by cold stress, hypoxia, and poor tissue perfusion, common in preterm infants.
Apnea is a common occurrence in preterm infants due to nervous system immaturity.
Apneic episodes are accompanied by bradycardia and cyanosis.
Gentle rubbing of the infant’s feet and back, suctioning the nose and mouth, and raising the infant's head can help stimulate breathing.
If breathing doesn't resume, an Ambu bag can be used.
Neonatal hypoxia is insufficient oxygenation at the cellular level.
A pulse oximetry level of 92% or greater is considered normal and should be monitored closely.
Severely anemic infants or those with abnormal RBCs may experience severe hypoxia without exhibiting cyanosis.
Pulse oximetry needs to be placed properly for accurate reading.
Sepsis is a generalized bloodstream infection that is a risk for preterm newborns due to their underdeveloped immune system.
The preterm infant's liver is immature and produces antibodies poorly.
The underdeveloped body enzymes and lack of maternal immunity, coupled with insufficient nutrient stores, make preterm infants vulnerable to sepsis.
Sepsis may not have local signs, making diagnosis difficult.
Sepsis symptoms include low temperature, lethargy or irritability, poor feeding, and respiratory distress.
Treatment involves intravenous antimicrobials, maintenance of warmth, nutrition, and close monitoring of vital signs.
Maintaining strict Standard Precautions and separating the infant from other infants in the unit is essential.

Poor Control of Body Temperature

Preterm infants lack sufficient brown fat insulation, leading to heat loss through radiation from a large surface area.
The immature heat-regulating center of the brain, non-functional sweat glands, weak muscles, and inactive nature make preterm infants prone to cold stress.
Cold stress increases oxygen and glucose needs, putting already vulnerable preterm infants at risk.
Skin temperature drops before core temperature falls, making skin probes crucial for monitoring preterm infant temperatures.
Radiant warmers or incubators are used to create a warm environment for preterm infants.

Hypoglycemia and Hypocalcemia

Hypoglycemia is common in preterm infants due to insufficient glycogen and fat stores.
Hypoglycemia is aggravated by conditions like asphyxia, sepsis, RDS, and unstable body temperature.
Plasma glucose levels below 40 mg/dL in a term infant and 30 mg/dL in a preterm infant indicate hypoglycemia.
Frequent glucose monitoring and providing nasogastric or parenteral feedings are essential for preterm infants
Hypocalcemia, a deficiency of calcium in the blood, is also common in preterm infants.
Preterm infants are at increased risk for hypocalcemia due to insufficient calcium reserves.
Hypocalcemia can be aggravated by hypoxia, birth trauma, administration of sodium bicarbonate, and maternal diabetes or low vitamin D intake.
Early hypocalcemia can cause the parathyroid gland to fail to respond adequately to low calcium levels.
Later hypocalcemia, usually occurring around 1 week of age, is linked to cow’s milk consumption, which increases serum phosphate levels and reduces calcium levels.
Treatment for hypocalcemia involves intravenous calcium gluconate and administering calcium lactate powder to formula.
Neonatal tetany can occur if calcium lactate powder is abruptly discontinued.

Increased Tendency to Bleed and Retinopathy of Prematurity

Preterm infants are more prone to bleeding due to deficient prothrombin levels, a clotting factor.
Fragile capillaries in the head are particularly susceptible to injury during delivery, causing intracranial hemorrhage, which can be detected through ultrasonography.
Monitoring for bulging fontanelles, lethargy, poor feeding, and seizures is essential for preterm infants.
Retinopathy of prematurity (ROP) is a disorder of the developing retina in premature infants that can cause blindness.
The condition is also known as retrolental fibroplasia, but ROP is the preferred term due to its greater precision.
ROP is the leading cause of blindness in newborns weighing less than 1500 g (3.3 lb).
ROP is caused by a defective vascularization process in preterm infants, often aggravated by high oxygen levels needed for survival.
ROP can lead to fibrous tissue growth behind the lens of each eye and retinal detachment, causing blindness.

Retinopathy of Prematurity (ROP)

Premature infants born with fully developed vascular systems in the retina are typically not affected.
Infants with unstable health conditions should be monitored for ROP.
The American Academy of Pediatrics (AAP) recommends routine retinal exams for infants born between 1500 and 2000g or with a gestational age less than 30 weeks.
Exams at 4 weeks of age and regular follow-ups can help detect and treat ROP early.
Retinal ablative therapy using laser photocoagulation or intravitreal bevacizumab injections can prevent blindness.
Follow-up for other eye issues (strabismus, refractive errors, cataracts) should occur within 4-6 months after NICU discharge.

Nursing care for Preterm Infants - Nutrition & Necrotizing Enterocolitis (NEC)

Premature infants have small stomach capacity and immature sphincter muscles, leading to regurgitation and vomiting.
They have immature sucking and swallowing reflexes.
Preterm infants have poor fat absorption, including fat-soluble vitamins.
Limited nutrient stores and increased glucose and nutrient needs contribute to nutritional challenges.
Orogavage feedings are preferred over nasal gavage due to newborns being obligatory nose breathers.
Monitor abdominal girth and bowel sounds for early signs of NEC.
Oral feeding readiness is signaled by a strong gag reflex, sucking, and rooting reflexes.
Start nipple feedings slowly, weight loss may occur initially due to feeding energy expenditure.
Positioning the baby on their right side or abdomen after feeding promotes gastric emptying and reduces aspiration risk.
NEC is an acute bowel inflammation leading to necrosis.
Premature newborns are at high risk due to compromised bowel lining blood supply, leading to mucosal damage and bacterial invasion.
Feeding milk formula or hypertonic gavage feeding can provide a medium for bacterial growth.
NEC signs include abdominal distention, bloody stools, diarrhea, and bilious vomit.
Nursing responsibilities include monitoring vital signs, maintaining infection control, and cautiously resuming oral fluids as ordered.
Treatment involves antibiotics and parenteral nutrition to allow the bowel to rest.
Surgical removal of necrosed bowel may be necessary.

Immature Kidneys and Jaundice

Preterm infants have immature kidneys, leading to ineffective waste elimination and electrolyte imbalances.
Dehydration occurs easily, salt tolerance is limited, and edema susceptibility is increased.
Documentation of intake and output for all preterm infants is essential.
Urine output should be 1-3 ml/kg/hr.
Closely monitor preterm infants for signs of dehydration or overhydration.
Document fontanelle status, tissue turgor, weight, and urine output.
Jaundice (icterus) is caused by liver immaturity in newborns.
Jaundice causes yellow discoloration of the skin and whites of the eyes.
The liver cannot efficiently clear bile pigments from the blood.
Serum bilirubin levels (mg/dL) indicate the severity of jaundice and the risk of neurological damage.
A bilirubin increase exceeding 5mg/dL within 24 hours or levels greater than 12.9 mg/dL require thorough evaluation.
Physiological jaundice is common and usually resolves on its own.
Pathological jaundice is more concerning, appearing within 24 hours of birth, and is often linked to ABO-Rh incompatibility.
Preterm infants have slower bilirubin rise and prolonged jaundice duration, increasing the risk of hyperbilirubinemia.
Breastfed infants may have higher jaundice levels, especially early onset.
Late onset jaundice in breastfed infants may be due to breast milk inhibiting bilirubin conjugation; formula substitution may be needed.
Total serum bilirubin levels peak 3-5 days after birth.
Early discharge necessitates follow-up visits within 2 days to assess bilirubin levels.
The main goals of hyperbilirubinemia treatment are to prevent kernicterus (bilirubin encephalopathy) and halt further bilirubin elevation.
Nursing care includes:
- Observing jaundice progression, particularly from face to abdomen and feet.
- Monitoring and reporting bilirubin lab values.
- Documenting the infant’s response to phototherapy.

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.
Temperature, air, radiating surfaces, and humidity are controlled.
The incubator’s temperature is adjusted to maintain the infant’s temperature between 97.1-98.6°F (36.2-37°C).

Radiant Heat Cribs

Radiant heat cribs offer easier patient access while maintaining a neutral thermal environment.
The use of a Plexiglas shield with the radiant warmer is discouraged as it may block infrared heat.
A reflective patch should cover the skin temperature probe to prevent interference from the radiant warmer's infrared heat.

Kangaroo Care

This involves skin-to-skin contact between the infant and parent for warmth and bonding.
The infant rests on the parent's bare chest, wearing just a diaper and cap.
The parent wears a gown open in the front exposing their chest.
Kangaroo care promotes infant stabilization and later development.

Feeding of the Preterm Newborn

Feeding methods vary based on gestational age and health status.
The ability to coordinate breathing, sucking, and swallowing doesn’t develop before 34 weeks of gestation.
Very preterm infants may require gavage feedings (tube through the nose or mouth into the stomach).
Infants heavier than 1500g (3.3lbs) may tolerate bottle feeding with a small, soft nipple with a large hole.
Human milk is ideal, as fat is easily absorbed.
Intravenous fluids can supplement for fluid, calorie, and electrolyte needs in smaller, weaker infants.
Early feeding initiation reduces the risk of hypoglycemia, hyperbilirubinemia, and dehydration.
Monitor bowel sounds and meconium passage for intestinal readiness for oral feedings.
If gavage feeding, aspirate stomach contents before feeding.
Feeding can proceed if only mucus or air is aspirated.
If liquid residue is present, notify the physician before feeding.

Close Observation of the Preterm Newborn

Preterm infants require close observation of physical and behavioral responses.
Observations include:
General activity
Fontanelles
Eyes
Respirations
Pulse
Abdomen
Cord
Feeding
Voiding
Stools
Mucous membranes
Color
Skin

Positioning and Nursing Care

Positioning on the side or prone with slight head elevation (unless contraindicated) allows for better breathing, drainage of secretions, and reduced aspiration.
Propping on the side or prone position can reduce respiratory effort, improve oxygenation, promote organized sleep, and conserve energy.
Nesting can provide a calming, supportive environment promoting body flexion.
Gradually wean the infant from the prone position as condition stabilizes, and transition to the supine position before NICU discharge.
Teach parents about the "back-to-sleep" concept to prevent SIDS.
Avoid prolonged positioning due to discomfort and potential lung harm.
Change position regularly to prevent pressure sores on delicate skin.
Use air exposure and appropriate ointments for diaper rash as prescribed.
Avoid harsh soaps, alcohol, and medicated wipes on sensitive skin.
Use hydrocolloid adhesives, gauze, or cotton under tape.
Maintain hygiene with daily eye, mouth, and diaper cleansing and baths two to three times weekly with emollients.
Create a quiet environment and coordinate care to minimize overstimulation.
Use blankets, dimmer lights, and eye patches to protect the infant.
Awaken the infant slowly and gently for procedures and care, using gentle movement and maintaining flexion of the arms.
Encourage non-nutritive sucking.
Co-bedding of twins may enhance growth and development but requires further research for infection risks.

Use of Complementary Medicine in the NICU

Aromatherapy is used to enhance comfort by placing a mother’s clothing with her natural scent near the infant.
Other aromatherapy applications are under research.
Music therapy can calm infants and enhance language development, particularly through parent singing.
Gentle therapeutic touch and massage offer numerous benefits to preterm infants by reducing motor activity, conserving energy, and promoting bonding with parents.

Prognosis of the Preterm Infant

Preterm infants typically catch up in growth by the second year of life, unless severe birth defects or complications are present.
Very-low-birth-weight infants may experience challenges and require additional support to achieve normal growth development.
Parents should expect and be prepared for comments from relatives about the infant's size and development.
Growth and development of the preterm infant are determined by adjusting for the weeks of prematurity; for example, a one-month-old infant born at 36 weeks of gestation will be at a newborn's developmental level.

Family Reaction to the Preterm Infant

Nurses play a crucial role in supporting parents to cope with the challenges of caring for a preterm infant.
Parents may experience emotions such as sadness, guilt, fear, and difficulty bonding with the infant.
The nurse should encourage the mother to participate in infant care, starting with basic activities like diapering, bathing, and feeding.
Encourage parents to express their feelings and provide education on home care.

Characteristics of the Post Term Infant

A post-term infant is born after 42 weeks of gestation.
The primary goal is to identify infants who are not tolerating the extended time in the uterus.
Post-maturity refers to the infant exhibiting characteristics of the post-mature syndrome.
The placenta ages and may not function adequately as the pregnancy progresses, potentially causing fetal distress.

Problems Associated with Postterm Infants

Asphyxia due to chronic hypoxia in the uterus.
Meconium aspiration, which can occur if the infant experiences hypoxia and distress.
Poor nutritional status and hypoglycemia related to depleted glycogen stores.
Polycythemia due to intrauterine hypoxia.
Difficult delivery due to the increased size of the infant.
Birth defects.
Seizures as a result of the hypoxic state.

Physical Characteristics of the Post Term Infant

Long and thin appearance with a potential for weight loss.
Loose skin, especially around the thighs and buttocks.
Little lanugo (downy hair) or vernix caseosa, leading to dry, wrinkled skin.
Long nails that may be stained with meconium.
Thick head of hair and alert appearance.

Nursing Care of the Post Term Infant

Labor induction or Cesarean delivery may be recommended if the pregnancy is past 42 weeks or there are signs of fetal distress.
Close monitoring of infants is essential, including respiratory distress, hypoglycemia, and hyperbilirubinemia.
Post-term infants may require an incubator due to their vulnerability to cold stress.

Transporting the High-Risk Newborn

High-risk newborns may require transportation to a regional neonatal center, involving a specialized team.
Before transport, it's important to stabilize the infant with vital signs, glucose levels, blood gases, and weight.
Copies of all records, including maternal prenatal history and delivery information, are necessary.
A transport incubator should be prepared with fully charged batteries.
Ensure accurate identification of the infant with matching identification bands.
Keep parents informed of the transport process and provide opportunities for bonding.

Discharge of the High-Risk Newborn

Discharge planning begins at birth and includes educating parents on routine and specialized care.
Nurses should provide home visits and support for families caring for high-risk newborns.
Emphasis should be placed on well-baby examinations, immunizations, infection prevention, and good prenatal care for subsequent pregnancies.
Communication and support group referrals are crucial for families.

Neutral Thermal Environment

Maintaining a neutral thermal environment is crucial for preterm infants to conserve energy and prevent heat loss.
This can be achieved through methods like radiant warmers, skin-to-skin contact (kangaroo care), and minimizing exposure to cold surfaces.

Gavage Feeding

Gavage feeding may be necessary for infants who are unable to feed orally.
The feeding tube should be inserted carefully and positioned correctly to minimize the risk of complications.

Nursing Care of Infants with Jaundice Receiving Phototherapy

Infants with jaundice may receive phototherapy to reduce bilirubin levels.
Nurses should closely monitor the infant's progress, protect the infant's eyes, and ensure adequate hydration while under phototherapy.

Kangaroo Care and Skin-to-Skin Therapy

Kangaroo care involves skin-to-skin contact between the parent and infant to regulate temperature, promote bonding, and provide comfort.
This approach can be beneficial for infants with various conditions, including prematurity.

Discharge Teaching for Families of Infants in the NICU

Prior to discharge, it's important to educate families on the infant's specific needs, including monitoring, feeding, medications, and developmental milestones.
Ensuring that all necessary equipment and resources are available for home care.
Provide contact information for healthcare professionals and support groups.

Review of Main Points

Preterm newborn care includes close monitoring of their health, providing comfort and support to the infant and family.
The nurse should be aware of potential complications of prematurity.
Postterm newborn care focuses on identifying and managing potential issues associated with prolonged gestation.
Discharge planning and follow-up care are important aspects of managing high-risk newborns.

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Test your knowledge about newborn classifications and terminology. This quiz covers definitions, gestational age categories, the Ballard scoring system, risk factors, and the significance of low birth weight in infants. Perfect for healthcare professionals and students in related fields.