OB Exam 5 Tutoring (PDF)

# OB Exam 5 Tutoring ## Physiologic Responses of the NB to Birth ### Fetal Respiratory System **Fetal Lung Development:** - 20-24 weeks alveolar ducts are present - Surfactant production starts at 28-32 weeks, when do we see production peak? - What's surfactant important for? **Normal Newborn...

# OB Exam 5 Tutoring ## Physiologic Responses of the NB to Birth ### Fetal Respiratory System **Fetal Lung Development:** - 20-24 weeks alveolar ducts are present - Surfactant production starts at 28-32 weeks, when do we see production peak? - What's surfactant important for? **Normal Newborn Respirations:** - Is their breathing regular or irregular? - Do they take pause when breathing? Is it normal for them to have apnea? - What is the normal range of breaths per minute? - They are diaphragmatic breathers - Are their breaths normally shallow or deep in depth? - Should their breathing be noisy or quiet? **Signs of Abnormal Respirations:** - Grunting (especially at rest) - Nasal flaring (struggling to breathe) - Retractions if they move upward, that is bad - Tachypnea - Apnea (what is considered apnea for this population?) - Circumoral and/or central cyanosis ### Cardiopulmonary System **Fetal Circulation:** - Ductus venosus - Foramen ovale - Ductus arteriosus **Normal Heart Rate:** - Heart rate at birth can be up to 180 beats per minute (this is normal) - Count apical pulse x1 minute - Blood pressure increases after birth and is normal around 3 hours after - Cardiac murmurs are they normal? Why or why not? - Is acrocyanosis okay? **Major Cardiopulmonary Changes:** - Closure of the foramen ovale - Closure of the ductus arteriosus - Closure of the ductus venosus **Abnormal Cardiac Patterns:** - Tachycardia > 160 at rest - Bradycardia < 100 at rest but not sleeping (when is a low heart rate okay?) - Circumoral or central cyanosis - Pale skin - Persistent loud cardiac murmurs (they should be?) **Mechanical Stimulation:** - Fluid filled lungs at first, what happens to cause them to be filled with air? - Lungs expand as air enters - What prevents lung collapse? **Chemical Stimuli:** - Increase in partial O2 and a decrease in CO2 levels - There is a decrease in circulating prostaglandins which keeps the cord open but when it is clamped they decrease - Sensory (auditory & tactile) baby is used to a dark and quiet environment but when they come out it is loud and bright and they are being touched & rubbed, which is new - What does the sensory stimuli stimulate in the newborn? - When we hear the baby cry is this good or bad? **Management for Abnormal Cardiac Signs** - Check pulse ox - Administer oxygen - 4 extremity blood pressure - Cardiac studies - Transfer to NICU if needed - Usually, we will check baby every 2 hours: in transition every 15 minutes in the first hour, every 30 minutes in the second hour, and every hour for the last 2 hours. ## Thermoregulation **What type of environment do we want to keep newborns in?** - Why? **Can newborns shiver?** **How do newborns generate heat?** **Brown fat increases with age why is this important?** **Generate heat by...** - Increasing muscle activity (restlessness and crying) - Increase in basal metabolic rate (more metabolism more heat produced) - Oxygen and glucose consumption increases - Nonshivering thermogenesis (what is this)? **Why are babies more likely to have heat loss?** - Heat transfer from organs to skin increases because of decreased subcutaneous fat and large body surface area to weight ratio - Blood vessels closer to skin **How do newborns reserve heat?** - Have a flexed posture which helps them to contract their muscles so that they can generate heat & it decreases surface area exposed to the environment - Peripheral vasoconstriction (reduces internal heat loss through body surface) **Where is brown adipose tissue located in the newborn?** - Sternum, between shoulder blades, and around the kidneys **Hypothermia:** - Why does this happen? - What do they do in response? **Non shivering thermogenesis:** - Relies on brown adipose tissue - This tissue has a dense cell content & intense lipid metabolic activity → generates heat when metabolized → warms the baby ## Types of Heat Loss 1. Flow of heat from the body surface to cooler ambient air 2. Loss of heat from the body surface to a cooler, solid surface not in direct contact, but in relative proximity 3. Loss of heat that occurs when a liquid is converted to vapor 4. Loss of heat from the body surface to cooler surfaces in direct contact ## Hepatic Adaptation **Metabolic end product of RBC breakdown:** **Changing of bilirubin into an excretable form that is water soluble:** **Fat soluble & not excretable (a potential toxin):** **Yellow discoloration of skin & sclera:** **Liver is responsible for...** - Iron storage - Glucose homeostasis - Conjugation of bilirubin **Elevated total serum bilirubin levels:** **Unconjugated:** **Hyperbilirubinemia:** **Conjugation** **Bilirubin:** **Jaundice:** ## Hepatic Adaptation **Conjugation of bilirubin:** - Unconjugated or indirect bilirubin - Fat soluble, not excretable, a potential toxin: what can happen if we don't get rid of it? - When it is conjugated → soluble and excretable - What conjugates the bilirubin after birth? - How is the unconjugated bilirubin transported in blood? - Why do we get a build up of unconjugated bilirubin? - Conjugated or direct bilirubin - Bilirubin becomes soluble and excreted into bile ducts and duodenum - Bacteria converts bilirubin – urobilinogen → stercobilinogen - How is bilirubin excreted? ## Types of Jaundice: **1. Physiologic Jaundice:** - Occurs AFTER 24 hours of life - Increase after day 3 – 5 and decreases by day 7 – 10. - Variation is based on gestational age, race, feeding pattern - Skin turns manila envelope yellow **How can we prevent this type of jaundice?** **1. Pathologic Jaundice:** - Occurs WITHIN 24 hours of life. - Mainly caused by ABO incompatibility, primary liver diagnosis, bile duct obstruction, or enzyme deficiency. **1. Breastfeeding jaundice:** - Associated to non-pathologic - Usually due to insufficient intake ## Hypoglycemia, TTN, & Hypothermia **Hypoglycemia** - Normal newborn glucose range is 70 to 90 - Signs and symptoms of hypoglycemia? - Could be asymptomatic, jitteriness, lethargy, apnea, feeding problems, seizures - What are some risk factors for hypoglycemia? - Macrosomia, cold stress, respiratory distress, premature/postmature, IUGR, LGA, IDM - What do we initiate immediately for hypoglycemia? **Transient Tachypnea of the Newborn** - Fast breathing alternating with apnea? - What are the risk factors? - Cesarean section babies, macrosomia, maternal diabetes, preterm, poor uterine perfusion, meconium ingestion **Hypothermia** - What are the signs and symptoms? - Pallor, jitteriness, cool, & mottled - Can hypothermia cause metabolic acidosis? - What is cold stress? - What are some signs and symptoms of cold stress? - Increased movement and respirations, decreased skin temperature & peripheral perfusion, developing hypoglycemia, metabolic acidosis, tremors, irritability, lethargy, apnea, seizure activity ## Question Time! 1. A nurse assesses a baby who was born 12 hours ago and finds that the baby's hands and feet are blue. Which of the following is the priority action? - Call the HCP - Document the finding as normal - Begin positive pressure ventilation - Apply 0.5 liter oxygen via nasal cannula 2. A nurse is assessing a 5 hour old newborn. Which of the following indicate that an infant is adapting to extrauterine life, as expected? Select all that apply. - Increased muscle tone - Passage of meconium - Heart rate of 160 beats/minute - Respiratory rate of 24 breaths/minute and irregular - Expiratory grunting with nasal flaring 3. A full-term newborn was just born and placed on the mother's chest. Which nursing intervention is important for the nurse to perform first? - Remove wet blankets. - Assess Apgar score. - Insert eye prophylaxis. - Elicit the Moro reflex. 4. To reduce the risk of hypoglycemia in a full-term newborn weighing 6 lbs 3 oz (2,900 grams), what should the nurse do? - Maintain the infant's temperature above 97.7° F (36.5° C). - Feed the infant glucose water every 3 hours until breastfeeding well. - Assess blood glucose levels every 3 hours for the first 12 hours. - Encourage the mother to breastfeed every 4 hours. # Nursing Care of Newborn and Family ## Ballard Score → Physical Maturity **Skin:** - Preterm baby – thin & transparent, veins are visible - Term baby – appears opaque d/t increase in _tissue_ - Lanugo: What is it?? – Decreases as gestational age – Most prominent is _weeks_ - Sole creases: Only reliable during the first 12 hours of life. **Which one is preterm and term?** **Areola:** - Term – it should measure 0.5 – 1 cm - *As gestation increases – areola and breast bud enlarge* **Ear form:** - Preterm: _& flat_ - Term: Springs back quickly from folding **Male Genitals:** - Term: Testes are in lower scrotum and is covered in rugae - Preterm: Small scrotum, few rugae, and testes are palpable in the inguinal canal **Female Genitalia:** - Term: Labia majora completely covers the labia minora & clitoris - Preterm: Clitoris is prominent and the labia majora are widely separated **Vernix:** - Preterm – completely covers the infant - Postterm – No vernix ## Skin Assessment & Head Assessment **Skin:** - If baby has cyanosis at rest and pink when crying – what is suspected? - Choanal atresia - Congenital blockage of passageway between the nose and pharynx - Mottling: Occurs with general circulation fluctuations - Jaundice: Determining the cause must be initiated to prevent further complications - Erythema toxicum: “newborn rash” – No treatment is necessary - Milia: White spot on the face that resemble pimples – How should the parent be educated? - Forcep marks: Nurse should document this **Head:** - Head is large - Fontanelle circumference of a term baby is typically: 32 – 37 cm - Molding: Overriding of cranial bones during labor & birth - Any extreme head sizes may indicate: - Microcephaly - Hydrocephalus - Fontanelles: - Anterior fontanel & posterior fontanel - Depressed: Dehydration - Bulging: Increased intracranial pressure ## Simple Reflexes of the NB **Sucking Reflex:** - Elicited when the newborn is supine, and the head is turned to one side. One side straightens and the other flexed **Tonic Neck Reflex:** - Elicited when the newborn is startled by a loud noise or lifted slightly above the crib and then suddenly lowered in response the newborn the arms and hands are straightened while the knees flexed **Palmar grasping reflex:** - Elicited when an object is placed in the newborn's mouth, or anything touches the lips. Disappears by 12 months **Moro Reflex:** - Elicited by stimulating the newborns palm with a finger or object the newborn grabs and holds the object **Rooting reflex:** - When held upright with one foot touching a surface, the newborn puts one foot in front of the other and walks **Stepping reflex:** - Elicited when the side of the newborns mouth or cheek is touched turns to side and open lips to suck ## Hyperbilirubinemia – Identify, Mx **What is it?** - Total serum bilirubin level in the blood is increased **Bilirubin needs to bind to albumin in order to be excreted – what are some causes that can lead to bilirubin not being attached to albumin? (unconjugated)** - Neonatal asphyxia - Indomethacin – drug - Hypothermia - Hypoglycemia - Maternal use – sulfa drugs & salicylates - Premies **Causes of hyperbilirubinemia:** - Hemolytic disease of the newborn - Erythroblastosis fetalis – when mom and baby don't have the same antibodies and they cross the placenta - Hydrops fetalis – most severe form of the erythroblastosis – antibodies attach to the Rh site on the fetal RBCs – severe anemia, MODS **Pathologic jaundice criteria:** - Clinically evident jaundice appearing before 24 hours of life or if it seems excessive for the age of the infant - Total serum bilirubin concentration by more than 0.2mg/dL per hour - Elevation of total serum bilirubin that requires phototherapy based on management algorithm *If any of these are present – it is considered pathologic* **Management:** **Goals** - Alleviating anemia, removing maternal antibodies, reducing serum bilirubin levels, minimizing the consequences of hyperbilirubinemia **Phototherapy:** - Exposure to the newborn to high intensity light to reduce serum bilirubin levels **Exchange transfusion:** - Withdrawal and replacement of the newborn's blood containing high level bilirubin with donor blood containing lower levels ## Question Time! 1. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. - Avoid stimulation. - Decrease fluid intake. - Expose all of the newborn’s skin. - Monitor skin temperature closely. - Reposition the newborn every 2 hours. - Cover the newborn’s eyes with eye shields or patches. 2. The nurse is performing an initial assessment on a newborn infant. When assessing the infant’s head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? - Document the findings. - Arrange for hearing testing. - Notify the health care provider. - Cover the ears with gauze pads. 3. The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? - Make a loud, abrupt noise to startle the newborn. - Stimulate the ball of the foot of the newborn by firm pressure. - Stimulate the perioral cavity of the newborn infant with a finger. - Stimulate the pads of the newborn infant’s hands by firm pressure. 4. Mom brings in her newborn into the clinic and explains to the nurse "My baby has these white bumps all over her face, I am nervous that it's a rash." How should the nurse reply? - OMG! This is a rash. We need to send her down the ER immediately. - This is completely normal and will go away eventually - Who cares? Your baby is fine. - You should pop them girl, they are ugly! 5. The nurse just handed the baby over to mom after delivery and the mother exclaims "Why is my baby so hairy?!" How should the nurse reply? - I have no idea! Let me call your physician. - Your baby came a bit earlier than expected and has lanugo, which is another word for "Fine hair". The hair will disappear as your baby grows. - Maybe you should shave it. - Call a code. # Acquired problems of NB ## Newborn injuries **Brachial Palsy:** - Partial or complete paralysis of portions of the arm - Results from: Trauma to the brachial plexus during a difficult birth **Erb Palsy:** - Damage to the upper arm (5 & 6th cranial nerves) is the most common type - The infant's arm lays limp at the side, elbow is held in extension, with forearm pronated - MORO reflex cannot be elicited on the affected side **Cephalohematoma:** - Collection of blood between cranial bone & periosteal membrane - DOES NOT CROSS THE SUTURE LINES - Appears between the 1st and 2nd day - Disappears after 2 – 3 weeks or may take months **Caput Succedaneum:** - Collection of fluid, edematous swelling of the scalp - CROSSES SUTURE LINES - Present at birth or shortly after - Reabsorbed within 12 hours or a few days after birth ## Substance abuse neonatal abstinence syndrome (NAS) **Clinical presentation of NAS:** - Respiratory = Include signs of RDS. - Neurologic = Irritability, tremors, shrill cry, hyperactivity, seizures, increased deep tendon reflexes, exaggerated moro reflex (startle reflex). - Note: When you see tremors first think hypoglycemia. - Autonomic dysfunction = Frequent yawning & sneezing, excessive sweating - Gastrointestinal = Abnormal feeding pattern, disorganized suck, increased gag reflex - **Do urine and meconium test** **Effects of drugs on infant:** - Tobacco = Smaller head circumference, cleft palate/lip, lower IQ, SIDS risk increase, prematurity - Alcohol = Craniofacial anomalies, microcephaly, mental retardation, fetal alcohol syndrome (FAS) - Marijuana = Social interaction problems, attention deficit disorder - Cocaine = Congenital anomalies, prematurity - Narcotics/opioid (heroin, methadone, morphine, oxycontin) = Prematurity, microcephaly, risk for SIDS. - **A common effect of substance abuse on all infants is IUGR** **Withdrawal symptoms:** - Approximate timing of withdrawal symptoms: - Alcohol in utero = within 3 – 12 hours after birth. - Narcotics in utero = 48 to 72 hours. - Barbiturates in utero = Between days 1 and 14. ## Question Time! 1. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? - Lethargy - Sleepiness - Constant crying - Cuddles when being held 2. *The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?* - Length of 19 inches - Abnormal palmar creases - Birth weight of 6 lb, 14 oz - Head circumference appropriate for gestational age ## Rationales: 1. A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held. 2. Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant. ## Question Time! 1. *The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?* - A suture split greater than 1 cm. - A hard, rigid, immobile suture line. - Swelling of the soft tissues of the head and scalp. - Edema that DOES NOT cross the suture lines. 2. The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? - Tremors - Bradycardia - Flaccid muscles - Extreme lethargy 3. Which would be considered a normal finding in a newborn less than 12 hours old? - Grunting respirations - Heart rate of 190 beats/minute - Bluish discoloration of the hands and feet - A yellow discoloration of the sclera and body # Nursing Care of the High-risk Newborn ## Care during the 1st 4 Hours of Life **Critical considerations → airway, body temperature, pain:** **Important Data we Can Use to Guide Care:** - Newborn status - Labor history - Maternal history (why is this important?) - Parent-newborn interaction **Important Events:** - 1 minute & 5 minute Apgar scores - First feeding (when should this happen) - Eye prophylaxis (why?) - Vitamin K administration (what does this help with?) - What do we do when vital signs are normal for the baby? - Assess tone: baby is comfortable if they are flexed, with arms/legs midline. *What would indicate poor tone?* - When would we intervene with poor tone? **APGAR scoring is performed at 1 and 5 minutes:** - What indicates a good score? - When we need to re-assess? ## Circumcision **Criteria:** - Newborn must be how many hours old? - Must have at least 1 void prior to the procedure **Important Things to Look For:** - What are we concerned about after the procedure? - What is one thing we continuously monitor for after the procedure? **Pain Management:** - How do we manage pain? - Sucrose & comfort measures like skin-to-skin swaddling & rocking - The area may also be deadened by topical creams, dorsal penile block, etc **Care Post-procedure:** - VS for about 1 hour and take back to mom - Clean with warm water with each diaper change - Which circumcision method uses vaseline gauze after and why does it help? - Apply light pressure for a bleed with sterile gauze if it is still bleeding – call HCP - Which method requires NO jelly, creams, or ointment and should be complete at around 7 – 10 days? - What will we not do position-wise? ## Preparation for Discharge & Security **How should the baby be sleeping at home?** **What do the parents need to have in order to leave hospital ?** **What if baby wants to eat on the way home?** **Make sure to emphasize f/u appointments!** **Immunizations (what do they get at the hospital?)** **What do we teach moms about timing to breastfeed?** **Make sure to dress baby correctly to prevent sunburns and hypothermia** **Should we bathe the baby every day? Are we scrubbing their skin when we bathe them?** **Security:** - ID bracelets/bands for the baby immediately after they are born - Use mom's 1st & last name and newborn's gender - What are some characteristics/behaviors of abductors? - What is something we can do to prevent abduction? **Behaviors of an abductor:** - Female of child-bearing age - Incapable of conceiving or loss of baby - Pretend to be a healthcare provider - Visit maternity ward to inquire about layout - Use stairway - Grab first opportunity ## Newborn infections - **HSV:** Transmitted during vaginal birth if _lesions_ are present. - **Rubella:** Cataracts, glaucoma, hearing loss, heart defects - **GBS and Listeriosis:** Meningitis - **Toxoplasmosis:** Hydrocephalus, preterm birth **What are some general signs and symptoms that may alert you to believing the newborn may have an infection?** - Glucose instability, bradycardia, apnea, grunting, lethargy, poor feeding, hypothermia, fever, temperature instability, cyanosis, etc. ## Who am I? **I am a multisystem disease:** **I am caused by a protozoan parasite commonly found in cats, dogs, pigs, sheep, and cattle.:** **My favorite host are cats. Definitely. Cats are my favorite.** **I can be avoided by cooking foods properly and asking someone else to handle the kitty litter duties for awhile.** **I have a classic triad of symptoms: hydrocephalus, chorioretinitis, and cerebral calcifications.** **I am rare in the United States:** **The earlier in a pregnancy I infect a mother, the more severe my effects.:** ** I can cause miscarriage or fetal death.:** **An infection with me during pregnancy is one of the few known causes of autism.** **If I can, I like to cause cataracts or glaucoma, hearing loss, and cardiac defects.** **I like to cause hearing loss the most.** **I can cause significant morbidity and mortality in the newborn:** **In utero, I can cause destruction of normally formed organs, resulting in IUGR, microcephaly, hydranencephaly, chorioretinitis, or fetal death.** **Most of the time, I am transmitted from mother to newborn through viral shedding during labor and birth.:** **In the clinic, providers like to classify me as follows: disseminated infection, CNS disease, or localized infection of the skin, eye, or mouth.:** **Cesarean birth is recommended for women with active genital lesions.** ## Question Time! *On which of the following is the APGAR score based? SATA* - Heart rate - Respiratory effort - Muscle tone - Reflex irritability - Color ## Question Time! *A nurse is teaching a mother how to care for her 3-day-old son’s circumcised penis. Which of the following actions demonstrates that the mother has learned the information?* - The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide. - The mother covers the glans with antifungal ointment after rinsing off any discharge. - The mother squeezes warm water from the washcloth over the glans. - The mother replaces the dry sterile dressing at each diaper change. ## Question Time! *The nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfeeding baby. Which of the following should the nurse include in the plan?* - Wash hands well before picking up the baby. - Refrain from having visitors for the first month. - Wear a mask to prevent transmission of a cold. - Sterilize the breast pump supplies after every use. # High Risk Newborn ## Alterations in Respiratory in Prematurity **Breathing pattern:** - Periodic with 5 – 10 second respiratory pauses followed by 10 – 15 seconds of compensatory rapid respirations; _breaths_ per minute. - Apnea should not exceed _seconds_ = Key because if it does, interventions need to happen ASAP: give oxygen, call MD. - Early signs of respiratory distress = Nasal flaring, expiratory grunting (bad) - Progression of symptoms = Seesaw breathing pattern, retractions, in addition to early signs; Color changes from pink to circumoral to generalized cyanosis. = Color changes indicate a compromised infant **Physiology:** - Decrease number of functional alveoli - Deficient surfactant levels - Smaller lumen in respiratory system - Respiratory system easier to collapse or have obstruction - Weak or absent gag reflex - Immature and fragile capillaries - Functional alveoli and capillary bed are distant from each other **Oxygen therapy:** - Neonatal resuscitation = Proceed to resuscitation only if needed. - Hood therapy = Infants that do not require mechanical pressure support - Nasal cannula = Infants requiring low-flow amounts of oxygen - CPAP = A noninvasive ventilation that reduces the need for mechanical ventilation. Used in infants that cannot maintain adequate partial oxygen despite the administration of oxygen using other means. - Mechanical ventilation- Method used when other means of therapy have failed to maintain oxygenation. **Signs of Respiratory Distress:** - Raised respiratory rate - Use of accessory muscles - Intercostal recessions - Subcostal recessions - Nasal flaring - Head bobbing - Tracheal tugging - Cyanosis - Abnormal airway noises ## Alterations in cardiac function in Prematurity - Monitoring of heart rate, blood pressure, oxygen saturation, perfusion pulses, acid-base status per unit's protocol. - Observe for signs of hypovolemia & shock = (hypotension, slow capillary refill, respiratory distress). - Blood pressure monitoring is not routine on the well newborn but required on the sick newborn; significant in making early diagnosis of cardiorespiratory disease **Bradycardia and Apnea in Premature Babies:** - Slow heartbeat = Bradycardia - Stopped breathing = Apnea ## At-Risk Newborns **Identification of At-Risk Newborns:** - Infants born at less than 37 completed weeks of gestation = Preterm (doesn’t matter their weight, if they haven't hit the 37 weeks = They are preterm) - Low body weight born after 37 weeks = Doesn’t mean preterm. **Preterm infants have immature systems and lack adequate nutrient reserves:** **Physiological disorders & anomalies may be present:** - Healthcare personnel and equipment need to be available for immediate care of the infant **Contributing Factors for Preterm Birth:** - Previous premature birth - Pregnant with multiples - Gynecological factors = Uterine and cervical or uterine abnormalities - Age = Increased if < 17 years or > 35 years old. - Obesity - Medical conditions = DM, high BP, preeclampsia - Infections = STIs - Social factors-smoking, use of alcohol, street drugs, abuse of prescribe drugs **Classification of High-Risk Infants:** - LBW = Less than 2500 grams - VLBW = Less than 1500 grams - ELBW = Less than 1000 grams - AGA = Birth weight 10th & 90th percentile - SFD/SGA = Intrauterine growth restriction - LGA = Falls above the 90th percentile **Surfactant = Administered to maintain lung expansion in preterm infants less than 37 weeks:** - Given in adjunct to oxygen and ventilation therapy - Preterm babies have less surfactant, administered by endotracheal tube ## SGA|IUGR|LGA - SGA = Small for gestational age (< 10 percentile of gestational age) - Know that growth is retarded by consistent low fundal height. - IUGR = Rate of growth is not consistent with gestational age. - Causes = Infections, teratogens, chromosomal abnormalities, maternal/placental factors - Maternal factors like smoking (cause vasoconstriction & poor perfusion) - Complications = Perinatal asphyxia (MAS (meconium aspiration syndrome) & hypoglycemia), hypoglycemia (inadequate intake or increased demands), polycythemia (increased risk for hyperbilirubinemia), heat loss - LGA= Large for gestational age falls above _percentile_ - Some are healthy, some are from gestational diabetes moms (hypoglycemia risk) - Observe for birth trauma resulting from delivery ## Postmature Newborns **Features:** - Dry cracked skin (desquamating), firm long nails, depleted subcutaneous fat (old person appearance), hypothermia, long thin body, meconium-stained, at risk for MAS, profuse scalp hair, decreased vernix (the cheese looking thing) **Other problems:** - SGA or IUGR may be present, perinatal asphyxia, hypoglycemia, hypothermia, polycythemia, LGA. - Assess infants for risk factors and address promptly to prevent further damage - Meconium aspiration syndrome (MAS)= Have to intubate to suction - Persistent pulmonary hypertension of the newborn (PPHN) = Occurs when normal vasodilation and relaxation of pulmonary vascular bed do not occur. This leads to elevated pulmonary vascular resistance, right ventricular hypertension, and right-to-left shunting of blood through the foramen ovale and ductus arteriosus. **Post term Infant Characteristics:** - Newborn emaciated - Meconium stained - Hair and nails long - Dry peeling skin - Creases cover soles - Limited vernix and lanugo ## Infants of Diabetic Mothers **Patho:** - Fluctuations in blood glucose & episodes of ketoacidosis results in fetal congenital abnormalities (early pregnancy). - Large amounts of glucose crosses placenta to fetus causing fetal pancreas to release insulin. - High levels of maternal glucose and nutrients in addition to fetal insulin results increase fetal growth = Macrosomia. - When ketoacidosis occurs, maternal blood becomes acidotic. The exchange of gases is minimal causes death (stillbirth occurs). **Risk and anomalies:** - Anomalies higher in type I and II diabetics - Occurs early in pregnancy due to high levels of glucose or Hb A1c. - Women with pre-pregnancy obesity at risk of anomalies. - Structural abnormalities occur before 8th week of pregnancy affect cardiac and renal function. **Problems:** - Birth trauma & perinatal hypoxia - RDS (Respiratory distress syndrome) - Hypoglycemia • Signs and symptoms = - Hypocalcemia & hypomagnesemia - Cardiomyopathy (increased heart size) - Hyperbilirubinemia & polycythemia (increased blood viscosity = impair circulation) **Infant of Diabetic Mother Common Problems:** - Congenital abnormalities - Macrosomia - Birth trauma - Perinatal asphyxia - RDS - Hypoglycemia - Hyperbilirubinemia - Polycythemia ## Alterations in thermoregulation in Prematurity **Factors:** - Predisposing large body surface in relation to body weight - Minimal subcutaneous fat = Inadequate insulation and limited stores of brown fat - This would happen if they were preterm or post-term (subcutaneous fat) - Fragile skin = Thinner and more permeable skin than term neonates - Poor muscle tone resulting in exposure of more body surface area - Extremities extended into hypotonic 'frog' position - Body isn't flexed- remember being flexed helps infants retain heat!!! - Decrease ability for vasoconstriction of capillaries **Maintaining Body Temperature:** - Transfer from delivery room to prewarmed radiant warmer or incubator - Skin-to-skin contact for stable preterm infants = Best - Keep head covered at all times - Maintain thermoneutral condition in preterm - Rewarm infants that are hypothermic = Radiant warmer - Preterm infant in polyethylene bag (ziploc bag lol) to protect against heat loss - Normal NB temp = 97.7 – 99.5 F (36.5 – 37.5 C) **Hypothermia:** - Skin = Pale, mottled, cool to touch - Respiratory = Apnea - Cardiac = Bradycardia, central cyanosis, hypoxia - Hypoglycemia - CNS = Irritability, lethargy - Weak cry or suck **Hyperthermia:** - Skin = Flushed skin, sweating, warm to touch - Respiratory = Apnea or tachypnea - Cardiac = Tachycardia - CNS = Depression, irritability, lethargy, seizures - Dehydration - Weak or absent cry ## Alterations in neuro in Prematurity **CNS:** - CNS = Prone to injury during prenatal, intranatal periods (head trauma during delivery, asphyxia), and post-birth. - Outcomes of injuries depend on its extent = May be normal or serious long-term problems such as seizures, neurological deficits, developmental disability, motor deficits, visual impairments, death. **Risk factors for CNS injuries:** - Prematurity. - Birth trauma = Difficult labor, traumatic delivery, forceps delivery. - Breech delivery. - Birth asphyxia, hypoxia, respiratory distress r/t maternal, uteroplacental, & fetal causes. **Functions:** - Clinical signs of neurologic dysfunction can be subtle, non-specific or specific. - Five categories of clinical manifestations for evaluation in preterm: - Seizure activity - Hyperirritability - CNS depression = Respiratory rate, not moving much, frontals depressed + bulging - Intracranial pressure (ICP) - Abnormal movements such as decorticate posturing - if strange posture think something wrong. **How Does An Immature Nervous System Predispose To Hypoxia?** - **Parasympathetic tone:** - Hypoxia causes bradycardia - Bradycardia causes hypotension - Bradycardia worsens hypoxia - **Children easily sedated:** - Immature neurons. - Less myelinization. - Weak blood-brain barrier. - Little prior exposure to drugs. - Increased risk respiratory depression - **Apnea of prematurity:** - The more premature, the greater the risk.