Module 7 High Risk Newborn 2023

HOLY ANGEL UNIVERSITY
School of Nursing and Allied Medical Sciences

Department of Nursing
NCM 109 – CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)
S.Y. 2022-2023 | 2nd Semester |Mid Term
Module 7: Nursing Care of a Family with a High-Risk Newborn
Description
Complications of preterm birth and low birth weight are the top killers of newborn babies globally. It
results to more than one million deaths each year and countless others of babies who survive and suffer lifelong
physical, neurological, or educational disability, often at great cost to families and society. In the Philippines,
almost half of children who die before their fifth birthday are newborns. Of those babies who die, 60 percent
succumb to complications brought about by prematurity and low birth weight. Learning to recognize these
infants at birth and organizing care for them can be instrumental in helping protect both their present and
future health. This module describes information on the care of newborns who are ill or who are born with a
significant variation in gestational age or weight.
Learning Outcomes
LO1 Integrate concepts, theories and principles of sciences and humanities in the formulation and application of
appropriate nursing care to high-risk newborn and family.
LO3 Assess high-risk newborn to determine whether safe transition to extrauterine life has occurred.
LO4 Formulate nursing diagnoses to address needs / problems of high-risk newborn and family.
LO5 Implement safe and quality nursing interventions to meet the needs and promote optimal outcomes of
high-risk newborn and family.
LO7 Evaluate expected outcomes for achievement and effectiveness of care.
LO8 Institute appropriate corrective actions to prevent or minimize complications of high-risk newborn.
Module Outline
I. Preterm infants
II. Post term infants
III. Illness of the newborn
1. Anemia of Prematurity
2. Apnea of Newborn
3. Hyperbilirubinemia
4. Acute Bilirubin Encephalopathy
5. Persistent Patent Ductus
6. Periventricular/Intraventricular Hemorrhage
7. Respiratory Distress Syndrome
8. Necrotizing Enterocolitis
9. Retinopathy of Prematurity
10. Sudden Infant Death Syndrome
11. Meconium Aspiration Syndrome
Module 7: Nursing Care of a Family with a High-Risk

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12. Fetal Alcohol Disorders

IV. Nursing Process
Module
Infants need to be evaluated as soon as possible after birth to determine their weight and gestational age as
classification by growth charts and gestational history is important to determine immediate health care needs
and to help anticipate possible problems. Birth weight is normally plotted on a growth chart.
• TERM infants born are those born after the beginning of week 38 and before week 42 of pregnancy
(calculated from the first day of the last menstrual period)
• PRETERM infants are those born before term (less than the full 37th week of pregnancy)
• POST TERM infants are those after the onset of 43 weeks
Normally, birth weight varies for each gestational week of age. Infants who fall between the 10th and 90th
percentiles of weight for their age regardless of gestational age are considered
appropriate for gestational age (AGA). Infants who fall below the 10th percentile of weight for their age are
considered small for gestational age (SGA). Those who fall above the 90th percentile in weight are considered
large for gestational age (LGA). Other terms used include:
• low-birth-weight infants (LBW): one weighing under 2500 g at birth.
• very-low-birth-weight infants (VLB): one weighing 1000 to 1500 g
• extremely very-low-birth-weight infants (EVLB): one weighing 500 to 1000 g
Infants in all these classifications have immediate needs that are different from or that are more
pronounced that the needs of AGA term newborns. Each of these categories also carries its own set of potential
risks.
I. Preterm infant
A preterm infant is traditionally defined as a live-born infant before the end of week 37 gestation. In
terms of the degree of care needed, they are further divided into:
• Late preterm: born between 34 and 37 weeks
• Early preterm: born between 24 and 34 weeks
Most preterm infant need intensive care form the moment of birth to give them their best chance of
survival without neurological aftereffects because they are more prone to:
• hypoglycemia
• intracranial hemorrhage
• respiratory distress syndrome
A. Common Factors associated with preterm birth
• Low socioeconomic level
• Poor nutritional status

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• Lack of prenatal care

• Multiple pregnancy
• Previous early birth
• Cigarette smoking
• Age of mother (less than 20 years old)
• First pregnancies and beyond fourth pregnancies
• Closely spaced pregnancies
• Abnormalities of the mother’s reproductive system, such as intrauterine septum
• Infections (UTI)
• Pregnancy complications
• Early induction of labor
• Elective cesarean birth
B. Assessment
Observing a number of physical findings and reflex resting is used to differentiate between term and
preterm newborns at birth (Fig. 1). Other characteristics of a preterm infant are:
• Head disproportionately large
• Ruddy skin with little subcutaneous fat making veins easily noticeable
• High degree of acrocyanosis
• Body covered of vernix caseosa
• Lanugo covering the back, forearms, forehead, and sides of the face
• Small anterior and posterior fontanelles
• Few or no creases on the soles of the feet
• Small eyes
• Myopic (nearsighted) because of a lack of eye globe depth
• Large ears in relation to the head

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Figure 1. Examples of physical examination findings and reflex test used to judge gestational age. (A) A
resting posture. (B) Wrist flexion. (C) Recoil of extremities (legs) (D) The scarf sign. (E) Heel to ear. (F)
Plantar creases. (G) Breast tissue. (H) Ears. (I) Male genitalia. (J) Female genitalia.
Dubowitz Maturity Scale

Dubowitz and colleagues (1970) devised a gestational rating scale that uses more extensive criteria. All
newborns appearing to be immature or who are light in
weight at birth or early by dates should be assessed by means of these more definitive criteria.

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• It can help determine whether a newborn needs immediate high-risk nursery intervention.
• The assessment consists of two portions:
1. physical maturity
2. neuromuscular maturity (Fig. 2).
• The first is a series of observations about skin texture, color, lanugo, foot creases, genitalia, ear,
and breast maturity.
• Each designated body part is inspected and given a score of 0 to 5, as described in Figure 2A.
• This observational scoring should be done as soon as possible after birth because skin
assessment becomes much less reliable after 24 hours.
• Illustrations of mature and immature body features for Ballard scale use are shown in Figure 1.
To complete the second half of the gestational examination, observe or position a newborn as
shown in Figure 2B.
• Again, score the child’s response numerically from 0 to 5.
• To establish a baby’s gestational age, the total score obtained (on both sections) is compared
with the rating scale in Figure 2C.
• An infant with a total score of 5 is at 26 weeks’ gestational age; a total score of 10 reveals a
gestational age of about 28 weeks; a total score of 40 points is found in infants at term or 40
weeks’ gestation.
• Using such a standard method to rate maturity is helpful in detecting infants who are small for
gestational age (they are light in weight, but the neuromuscular and physical observationscales
are adequate for their weeks in utero) and differentiating them from newborns who are
immature because of a miscalculated due date.
• An infant who is found to be less than 35 weeks’ gestation requires close observation, usually in a
special care nursery.

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Figure 2. Ballard’s assessment of gestational age criteria. (A) Physical maturity assessment criteria.
(B) Neuromuscular maturity assessment criteria. Posture: With infant supine and quiet, score as follows:
arms and legs extended _ 0; slight or moderate flexion of hips and knees _ 2; legs flexed and abducted,
arms slightly flexed _ 3; full flexion of arms and legs _ 4. Square Window: Flex hand at the wrist. Exert
pressure sufficient to get as much flexion as possible. The angle between hypothenar eminence and
anterior aspect of forearm is measured and scored. Do not rotate wrist. Arm Recoil: With infant supine,
fully flex forearm for 5 sec, then fully extend by pulling the hands and release. Score as follows: remain
extended or random movements _ 0; incomplete or partial flexion _ 2; brisk return to full flexion _ 4.
Popliteal Angle: With infant supine and pelvis flat on examining surface, flex leg on thigh and fully flex
thigh with one hand. With the other hand, extend leg and score the angle attained according to the chart.
Scarf Sign: With infant supine, draw infant’s hand across the neck and as far across the opposite shoulder
as possible. Assistance to elbow is permissible by lifting it across the body. Score according to location of
the elbow: elbow reaches opposite anterior axillary line _ 0; elbow between opposite anterior axillary line
and midline of the thorax _ 1; elbow at midline of thorax _ 2; elbow does not reach midline of thorax _ 3;
elbow at proximal axillary line _ 4. Heel to Ear: With infant supine, hold infant’s foot with one hand and
move it as near to the head as possible without forcing it. Keep pelvis flat on examining surface. (C)
Scoring for a Ballard assessment scale. The point total from assessment is compared to the left column.
The matching number in the right column reveals the infant’s age in gestation weeks.
II. Post term infants

A post term infant is one born after the 41st week of a pregnancy. An infant who stays in utero past
week 41 of pregnancy is at special risk because a placenta appears to function effectively for only 40
weeks. After that time, it seems to lose its ability to carry nutrients effectively to the fetus and the fetus
begins to loose weight (post term syndrome). Infants with this syndrome have many of the
characteristics of the SGA infant:
a. Dry, cracked, almost leather-like skin from lack of fluid
b. Absence of vernix
c. SGA
d. The amount of amniotic fluid may be less at birth than normal, and meconium stained.
e. Fingernails will have grown well beyond the end of the fingertips.
f. May demonstrate an alertness much more like a 2-week-old baby than a newborn.
When a pregnancy becomes postterm, a sonogram is usually obtained to measure the biparietal
diameter of the fetus. A nonstress test or complete biophysical profile may be done to establish whether
the placenta is still functioning adequately. A cesarean birth may be indicated if a nonstress test reveals
that compromised placental functioning may occur during labor.
Problems of postterm babies are:
a. Difficulty establishing respirations, especially if meconium aspiration occurred.
b. Hypoglycemia may develop because the fetus had to use stores of glycogen for nourishment
in the last weeks of intrauterine life.
c. Subcutaneous fat levels may also be low, having been used in utero.
d. Polycythemia may have developed from decreased oxygenation in the final weeks.
e. The hematocrit may be elevated because the polycythemia and dehydration have lowered
the circulating plasma level.

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Make sure a woman spends enough time with her newborn to assure herself that although birth did not
occur at the predicted time, the baby should do well with appropriate interventions to control possible
hypoglycemia or meconium aspiration. All postterm infants need follow-up care until at least school age
to track their developmental abilities. The lack of nutrients and oxygen in utero may have left them with
neurologic symptoms that will not become apparent until they attempt fine-motor task.
III. Illnesses of the newborns
1. Anemia of Prematurity
Many preterm infants develop a normochromic, normocytic anemia (normal cells, just few in
number), which can make infants appear pale, lethargic, and anorectic.
- Causes
a. Immaturity of the hematopoietic system (the effective production of red cells with an elevated
reticulocyte count may not begin until 32 weeks or pregnancy)
b. Destruction of red blood cells because of low levels of vitamin E. a substance that normally
protects red blood cells against oxidation.
c. Excessive blood drawing for electrolytes, complete blood counts, or blood gas analysis after
birth can potentiate the problem.
- Interventions
• Blood draws in preterm infants are coordinated to the fewest possible and a record of the
blood loss for these tallied.
• Delayed cord clamping at birth to allow a little more blood from the placenta to enter the
infant may also help reduce the development of anemia.
• DNA recombinant erythropoietin
• Vitamin E supplement (assist in formation of RBCs)
• Blood transfusion (RBC transfusion)
• Iron supplement
2. Apnea of Newborn
Many preterm babies, particularly those under 32 weeks of age, have an irregular respiratory pattern (a
few quick breaths, a period of 5 to 10 seconds without respiratory effort, a few quick breaths again, and
so on). There is no bradycardia with this irregular pattern (sometimes termed periodic respirations).
Although
the pattern is seen in term infants as well, it seems to be intensified by immaturity.
• With true apnea, the pause in respirations is more than 20 seconds and bradycardia does
occur.
• Preterm infants have great difficulty initiating respirations at birth because pulmonary
capillaries are still so immature.
• Lung surfactant does not form in adequate amounts until about the 34th to 35th week of
pregnancy.

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• Inadequate lung surfactant leads to alveola collapse with each expiration. This condition
forces an infant to use maximum strength to inflate lung alveoli each time.
• The soft rib cage of the preterm causes to collapse on expiration.
• The accessory muscles of respiration may be underdeveloped leaving preterm infants with
no backup muscles to use when they become fatigued.
• Breech-born infants are apt to expel meconium into the amniotic fluid. If the fetus aspirates
either vaginal secretions or meconium, the respiratory problem can be aggravated by
inflammation or pneumonia.
• Cesarean birth, although it has the advantage of reducing pressure on the immature head,
may lead to additional respiratory complications because of retained lung fluid.
- Interventions
• Gently stimulating an infant or flicking the sole of the foot often causes thee baby to
breathe again.
• Positive pressure ventilation and resuscitative interventions
• To prevent episodes of apnea:
a. maintain a neutral thermal environment and use gentle handling to avoid excessive
fatigue.
b. Suction gently and only when needed to minimize nasopharyngeal irritation which can
cause bradycardia because of vagal stimulation.
c. Use of indwelling nasogastric tubes to reduce the amount of vagal stimulation.
d. After feeding, observe an infant carefully because full stomach can put pressure to the
diaphragm compromising respirations. Burping also helps reduce this effect.
e. Caffein, a methylxanthine, may be prescribed to stimulate breathing.
f. Infants maybe discharged home with a monitoring device to be used for several months
of life to reduce the risk for sudden infant death syndrome.
g. Giving the mother oxygen by mask during the birth can help provide a preterm infant
with optimal oxygen saturation at birth (85%–90%).
h. Keeping maternal analgesia and anesthesia to a minimum also offers an infant the best
chance of initiating effective respirations.
3. Hyperbilirubinemia
It is a condition of the newborn where there is an elevated serum bilirubin level. Evaluation is
indicated when serum levels are greater than 12 mg/dL (180 mcmol/L) in a term newborn. The therapy
is aimed at preventing kernicterus, which results in permanent neurological damage resulting from the
deposition of bilirubin in the brain cells. This complication is also known as Acute Bilirubin
Encephalopathy.
- Assessment
a. Jaundice

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b. Elevated serum bilirubin levels

c. Enlarged liver
d. Poor muscle tone
e. Lethargy
f. Poor sucking reflex
- Interventions
a. Monitor for the presence of jaundice; assess skin and sclera for jaundice.
o Examine the newborn’s skin color in natural light.
o Press a finger over a bony prominence or tip of the newborn’s nose to press out
capillary blood from the tissues.
o Note that jaundice starts at the headfirst and spreads to the chest, abdomen, arms and
legs, and hands and feet, which are the last to be jaundiced.
b. Keep the newborn well hydrated to maintain blood volume.
c. Facilitate early, frequent feeding to hasten passage of meconium and encourage excretion of
bilirubin.
d. Report to the physician any signs of jaundice in the first 24 hours of life and any abnormal signs
and symptoms. This is also known as pathologic jaundice which may be due to sepsis or Rh
Incompatibility.
e. Prepare for phototherapy (bili-light or Bili blanket), and monitor the newborn closely during the
treatment.
- Phototherapy
a. A fetus’s liver processes little bilirubin in utero because the mother’s circulation does this for an
infant. With birth, exposure to light apparently triggers the liver to assume this function.
Additional light supplied by phototherapy appears to speed the conversion of unconjugated
(fat-soluble) into conjugated (water soluble) bilirubin.
b. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can
occur.
c. Expose as much of the newborn’s skin as possible.
d. Cover the genital area and monitor the genital area for skin irritation or breakdown.
e. Cover the newborn’s eyes with eye shields or patches; ensure that the eyelids are closed when
shields or patches are applied.
f. Remove the shields or patches at least once per shift (during a feeding time) to inspect the eyes
for infection or irritation and to allow for eye contact and bonding with the parents.
g. Measure the lamp energy output to ensure efficacy of the treatment (done with a special
device known as a photometer).
h. Monitor skin temperature closely.
i. Increase fluids to compensate for water loss.

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j. Expect loose green stools.

k. Monitor the newborn’s skin color with the fluorescent light turned off, every 4 to 8 hours.
l. Monitor the skin for bronze baby syndrome, a grayish brown discoloration of the skin; notify
the physician because this may indicate a complication of phototherapy.
m. Reposition the newborn every 2 hours; monitor the newborn closely.
n. Provide stimulation.
o. If treatment is done at home, teach the parents about care and indications of the need to notify
the physician.
p. After treatment, continue monitoring for signs of hyperbilirubinemia, because rebound
elevations can occur after therapy is discontinued.
q. Turn off the phototherapy lights before drawing a blood specimen for serum bilirubin levels,
and do not leave the blood specimen uncovered under fluorescent lights (to prevent the
breakdown of bilirubin in the blood specimen).
4. Acute Bilirubin Encephalopathy
• The destruction of brain cells by invasion of indirect or unconjugated bilirubin.
• This invasion results from the high concentration of indirect bilirubin that forms in the
blood stream from an excessive breakdown of red blood cells at birth.
• Preterm infants have acidosis due to poor respiratory exchange thereby making the brain
cells to be more susceptible to the effect of indirect bilirubin than usual.
• Preterm infants also have less serum albumin available to bind indirect bilirubin and
inactivate its effect.
f. Interventions
• Initiation of feeding
Bilirubin is removed from the body by being excreted through the feces. Therefore, the
sooner bowel elimination begins, the sooner bilirubin removal begins. Early feeding
stimulates bowel peristalsis and helps to accomplish this.
• Phototherapy
• Exchange transfusion
- Small amount of the infant’s blood (2 to 10 ml) are drawn from the infant’s umbilical vein
and then replaced with equal amounts of donor blood.
- The transfusion should be done under a radiant heat warmer to keep the infant warm to
prevent energy expenditure.
- Donor blood must be maintained at room temperature to prevent hypothermia.
- The type of blood used for transfusion is O Rh-negative blood.
- After the transfusion, closely observe the infant to be certain vital signs are stable and
there is no umbilical vessel bleeding or inflammation of the cord. Report bilirubin levels

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for 2 or 3 days after the transfusion to ensure the level of indirect bilirubin is not rising
again.
5. Persistent Patent Ductus
• Because preterm infants lack surfactant, their lungs are noncompliant, so it is more difficult
for them to move blood from the pulmonary artery into the lungs.
• This condition leads to pulmonary artery hypertension, which may interfere with closure of
the ductus arteriosus.
- Interventions
• Administer intravenous therapy cautiously to preterm infants to avoid increasing blood
pressure and further compounding this problem.
• Either indomethacin or ibuprofen may be administered to close the patent ductus
arteriosus.
• A side effect of indomethacin is oliguria, so urine output needs to be monitored closely if
this is used.
6. Periventricular/Intraventricular Hemorrhage.
• Preterm infants are prone to periventricular hemorrhage (bleeding into the tissue
surrounding the ventricles) or intraventricular hemorrhage (bleeding into the ventricles)
because they have both fragile capillaries and immature cerebral vascular development.
• When there is a rapid change in cerebral blood pressure, such as with hypoxia, intravenous
infusion, ventilation, or pneumothorax, capillaries rupture, brain anoxia distal to the
rupture.
• Intraventricular hemorrhage occurs most often in very low birth weight infants and is
classified as:
Grade 1, bleeding in the periventricular geminal matrix regions or germinal matrix, occurring
in one ventricle.
Grade 2, bleeding within the lateral ventricle without dilation of the ventricle
Grade 3, bleeding causing enlargement of ventricles.
Grade 4, bleeding in the ventricles and intraparenchymal hemorrhage
• A long-term effect of hemorrhage may be the development of hydrocephalus if there is
bleeding into the narrow aqueduct of Sylvius.
- Interventions
• Preterm infants often have a cranial ultrasound performed after the first few days of life to
detect if a hemorrhage has occurred.
• Infants with grade 1 or 2 bleeds have a good long-term prognosis.
7. Respiratory Distress Syndrome
• Formerly termed hyaline membrane disease most often occurs in preterm infants.

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• The pathologic feature of RDS is a hyaline-like (fibrous) membrane formed from an exudate
of an infant’s blood that begins to line the terminal bronchioles, alveolar ducts, and alveoli.
• This membrane prevents exchange of oxygen and carbon dioxide at the alveolar–capillary
membrane.
• The cause of RDS is a low level or absence of surfactant, the phospholipid that normally lines
the alveoli and reduces surface tension to keep the alveoli from collapsing on expiration.
• Because surfactant does not form until the 34th week of gestation, as many as 30% of low-
birth-weight infants and as many as 50% of very-low-birth-weight infants are susceptible to
this complication.
• High pressure is required to fill the lungs with air for the first time and overcome the
pressure of lung fluid: (40 and 70 cm H2O to inspire a first breath but only 15 to 20 cm H2O
to maintain quiet, continued breathing)
• The decrease lung surfactant production results to cascades of events:
1. The alveoli collapse with each expiration.
2. Areas of hypo inflation begin to occur and pulmonary resistance increases.
3. Shunting of blood through the foramen ovale and the ductus arteriosus as it did during
fetal life.
4. Tissue hypoxia causes the release of lactic acid.
5. Formation of hyaline membrane on the alveolar surface
6. Acidosis causes vasoconstriction and decreased pulmonary perfusion from
vasoconstriction further limits surfactant production.
7. With decreased surfactant production, the ability to stop alveoli from collapsing with
each expiration becomes impaired.
8. This vicious cycle continues until the oxygen–carbon dioxide exchange in the alveoli is
no longer adequate to sustain life without ventilator support.
- Prevention
a. Dating a pregnancy by sonogram and by the level of lecithin in surfactant
b. Using tocolytic to prevent preterm birth.
c. Administer glucocorticosteroid, such as betamethasone to quicken formation of lecithin.
- Assessment
Most infants who develop RDS have difficulty initiating respirations at birth. After resuscitation,
they appear to have a period of hours or a day when they are free of symptoms because of an initial
release of surfactant. During this time, however, subtle signs may appear:
a. Low body temperature
b. Nasal flaring
c. Tachypnea (more than 60 respirations per minute)
d. Cyanotic mucous membranes

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Within several hours, expiratory grunting, caused by closure of the glottis as it tries to increase
the pressure in alveoli on expiration in order to help to keep them from collapsing. Even with this
attempt at better oxygen exchange, however, as the disease progresses, infants become cyanotic
and their PO2 and oxygen saturation levels fall in room air. On auscultation, there may be fine rales
and diminished breath sounds because of poor air entry. As distress increases, an infant may exhibit:
a. Seesaw respirations (on inspiration, the anterior chest wall retracts and the abdomen
protrudes; on expiration, the sternum rises)
b. Heart failure evidenced by decreased urine output and edema of the extremities.
c. Pale gray skin
d. Periods of apnea
e. Bradycardia
f. Pneumothorax
• The Silverman and Andersen index, originally devised in 1956 (Silverman & Andersen, 1956), can be
used to estimate degrees of respiratory distress in newborns.
• For this assessment, a newborn is observed and then scored on each of five criteria (Fig. 3). Each
item is given a value of 0, 1, or 2; the values are then added. A total score of 0 indicates no
respiratory distress. Scores of 4 to 6 indicate moderate distress. Scores of 7 to 10 indicate severe
distress. Notice that the scores of this index run opposite to those of the Apgar: an Apgar score of 7
to 10 would indicate a well infant.
Figure 3. Silver and Andersen index can be used to estimate degrees of respiratory distress in
newborns.

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The diagnosis of RDS is made on the clinical signs:

a. grunting
b. central cyanosis in room air
c. tachypnea
d. Nasal flaring and retractions
e. shock.
f. chest radiograph will reveal a diffuse pattern of radiopaque areas that look like ground glass
(haziness).
g. Blood gas studies (taken from an umbilical vessel catheter) will reveal respiratory acidosis.
- Interventions
a. Surfactant Replacement.
• Surfactant restores naturally occurring lung surfactant to improve lung compliance. This given to
prevent and treat RDS.
• Administered intratracheally, four doses in first 48 hours of life
• Suction infant before administration
• Assess infant’s respiratory rate, rhythm, oxygen saturation, and color before administration.
• Ensure proper endotracheal tube placement before dosing
• Change infant’s position during administration to encourage the drug to flow to both lungs.
• Assess infant’s respiratory rate, color and pulse oximetry or arterial blood gases after
administration.
• Do not suction endotracheal tube for 1 hour after administration to avoid removing the drug.
b. Oxygen Administration
• Administration of oxygen is necessary to maintain correct PO2 and pH levels following
surfactant administration, and it may be administered in a variety of ways from a simple cannula
or mask, continuous positive airway pressure (CPAP) or assisted ventilation with positive end-
expiratory pressure (PEEP).
• The advantage of CPAP or PEEP is that this will exert pressure on the alveoli at the end of
expiration and keep the alveoli from collapsing in addition to supplying oxygen.
• A possible complication of oxygen therapy in the very immature or very ill infant is retinopathy
of prematurity or bronchopulmonary dysplasia
c. Ventilation.
• Normally, on a ventilator, inspiration is shorter than expiration, or there is an
inspiratory/expirator ratio (I/E ratio) of 1:2.
• It is difficult to deliver enough oxygen to stiff, noncompliant lungs in this usual ratio, however,
without forcing the air into the lungs at such a high pressure and rapid rate that a
pneumothorax becomes a constant concern.

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• Infant ventilators are therefore available with a reversed I/E ratio (2:1). These are pressure-
cycled to control the force with which air is delivered.
• Complications of any type of ventilation are possible, such as pneumothorax and impaired
cardiac output because of decreased blood flow through the pulmonary artery from lung
pressure.
• There is also a possible risk of increased intracranial and arterial pressure and hemorrhage from
changing blood pressure.
• Being certain that infants are not overhydrated is important to help prevent increased blood
pressure and increased pulmonary artery pressure.
d. Additional therapy
• Nitric Oxide
A potent vascular dilator. It causes pulmonary vasodilation without decreasing systemic
vascular tone and redirects pulmonary blood. It combines with hemoglobin which causes
systemic vasodilation.
• Extracorporeal Membrane Oxygenation (ECMO)
It was developed as a means of oxygenating during cardiac surgery. Its current use has
expanded to include the management of severe hypoxemia in newborn with illnesses such
as meconium aspiration, RDS, pneumonia and diaphragmatic hernia.
8. Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) is a gastrointestinal disease. Premature newborns are at the
greatest risk for developing the disease, approximately 5% of all infants in intensive care
nurseries.
• The bowel develops necrotic patches, interfering with digestion and possibly leading to a
paralytic ileus, perforation and peritonitis.
• The necrosis appears to result from ischemia or poor perfusion of blood vessels in sections
of the bowel. The ischemic process may occur when, owing to shock or hypoxia, there is
vasoconstriction of blood vessels to organs such as the bowel.
• The entire bowel may be involved, or it may be a localized phenomenon.
- Assessment
• Signs of NEC usually appear in the first week of life.
• The infant’s abdomen becomes distended and tense.
• The stomach does not fully empty by the next feeding time because of poor intestinal
action; if the stomach contents are aspirated before a feeding, a return of undigested milk
of more than 2 mL will be obtained.
• Stool may be positive for occult blood.
• Periods of apnea may begin or increase in number.

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• Signs of blood loss because of intestinal bleeding, such as lowered blood pressure and
inability to stabilize temperature, also may be present.
• Abdominal x-ray films show a characteristic picture of air invading the intestinal wall; if
perforation has occurred, there will be air in the abdominal cavity.
• Abdominal girth measurements made just above the umbilicus every 4 to 8 hours increase.
- Interventions
a. The infant is maintained on IV or total parenteral nutrition solutions to rest the GI tract with the
additional supplement of enteral probiotics.
b. An antibiotic may be given to limit secondary infection.
c. Handle the abdomen gently to lessen the possibility of bowel perforation.
d. If the area of necrosis appears to be localized, surgery to remove that portion of the bowel may
be successful.
e. If a large portion of the bowel is removed, the infant may be prone to “short bowel” syndrome
or may have a problem with digestion of nutrients in the future.
f. If the bowel perforates, peritoneal drainage or a laparotomy will be necessary to help remove
fecal secretions from the abdomen.
g. An infant may need a temporary colostomy performed to allow for bowel function.
h. NEC is a grave insult to an infant already stressed by immaturity. The prognosis is guarded until
the infant can again take oral feedings without bowel complications.
9. Retinopathy of Prematurity
• Retinopathy of prematurity (ROP), an acquired ocular disease that leads to partial or total
blindness in children.
• It is caused by vasoconstriction of immature retinal blood vessels.
• Immature retinal blood vessels constrict when exposed to high oxygen concentrations.
• The endothelial cells in the layer of nerve fibers in the periphery of the retina proliferate, leading
to retinal detachment and blindness.
• Infants who are most immature and most ill (and consequently receive the most oxygen) are at
highest risk.
• A preterm infant who is receiving oxygen must have blood PO2 levels monitored by pulse
oximeter, transcutaneous oxygen saturation, or blood gas monitoring.
- Interventions
a. Conscientious management of oxygen.
b. Keeping blood PO2 levels within normal limits lowers the risk.
c. When blood PO2 levels rise to higher than 100 mm Hg, the risk of the disease increases greatly.
d. Cryosurgery or laser therapy may be effective in preserving sight.

19
Newborn
e. A person experienced in recognizing ROP should examine the eyes of all low-birth-weight
newborns and those who have received oxygen therapy before discharge from a hospital
nursery and again at age 4 to 6 weeks of age to detect any occurrence of the syndrome.
10. Sudden Infant Death Syndrome (SIDS)
SIDS is sudden unexplained death in infancy. It tends to occur at a higher-than-usual rate in infants
of adolescent mothers, infants of closely spaced pregnancies, and underweight and preterm infants.
Although the cause of SIDS is unknown, in addition to prolonged but unexplained apnea, other
possible contributing factors include:
• Sleeping prone rather than supine
• Viral respiratory or botulism infection
• Exposure to secondary smoke
• Pulmonary edema
• Brain stem abnormalities
• Neurotransmitter deficiencies
• Heart rate abnormalities
• Distorted familial breathing patterns.
• Decreased arousal responses.
• Possible lack of surfactant in alveoli
• Sleeping in a room without moving air currents (the infant rebreathes expired carbon
dioxide)
Typically, affected infants are well nourished. Parents report that an infant may have had a slight
head cold. After being put to bed at night or for a nap, the infant is found dead a few hours later.
Infants who die this way do not appear to make any sound as they die, which indicates they die with
laryngospasm. Although many infants are found with blood-flecked sputum or vomitus in their
mouths or on the bedclothes, this seems to occur as the result of death, not as its cause. An autopsy
often reveals petechiae in the lungs and mild inflammation and congestion in the respiratory tract.
However, these symptoms are not severe enough to cause sudden death. It is clear these children
do not suffocate from bedclothes or choke from overfeeding, underfeeding, or crying. Since the
American Academy of Pediatrics made the following recommendations
a. put newborns to sleep on their back and with a pacifier,
b. use of firm sleep surface
c. breastfeeding
d. room sharing without bed sharing
e. routine immunization
f. avoidance of soft beddings and overheating
g. avoidance of exposure to tobacco, alcohol, and illicit drugs.
With the above interventions, the incidence of SIDS has declined almost 50%.

20
Newborn
Parents have a difficult time accepting the death of any child. This can be especially difficult when it
happens so suddenly. In discussing the child, they often use both the past and present tense as if
they are not yet aware of the death. Many parents experience a period of somatic symptoms that
occur with acute grief, such as nausea, stomach pain, or vertigo. Parents should be counseled by a
nurse or someone else trained in counseling at the time of the infant’s death; it helps if they can talk
to this same person periodically for however long it takes to resolve their grief.
Autopsy reports should be given to parents as soon as they are available (if toxicology tests are
included in the autopsy, results will not be available for weeks). Reading that their child’s death was
unexplained can help to reassure parents the death was not their fault. They need this assurance if
they are to plan for other children. If there are older children in the family, they also need assurance
that SIDS is a disease of infants and that the strange phenomenon that invaded their home and
killed a younger brother or sister will not also kill them. If they wished the infant dead, as all children
wish siblings were dead on some days, they need reassurance that their wishes did not cause the
baby’s death.
When another child is born, parents can be expected to become extremely frightened at any sign of
illness in their child. They need support to see them through the first few months of the second
child’s life, particularly past the point at which the first child died. Some parents may need support
to view a second child as an individual child and not as a replacement for the one who died.
When another child is born to a family in which a SIDS infant died is screened using a sleep
assessment as a precaution within the first 2 weeks of life if the parents’ level of anxiety is acute,
before hospital discharge. The baby may then be placed on continuous apnea monitoring pending
the results of the sleep assessment.
11. Meconium Aspiration Syndrome
Meconium is present in the fetal bowel as early as 10 weeks’ gestation. If hypoxia occurs, a vagal
reflex is stimulated, resulting in relaxation of the rectal sphincter. This releases meconium into the
amniotic fluid. Babies born breech may expel meconium into the amniotic fluid from pressure on
the buttocks. In both instances, the appearance of the fluid at birth is green to greenish black from
the staining. Meconium staining occurs in approximately 10% to 12% of all pregnancies; in 2% to 9%
of these pregnancies, infants will aspirate the meconium. Meconium aspiration does not tend to
occur in extremely low-birth-weight infants because the substance has not passed far enough in the
bowel for it to be at the rectum in these infants.
An infant may aspirate meconium either in utero or with the first breath at birth. Meconium can
cause severe respiratory distress in three ways:
a. It causes inflammation of bronchioles because it is a foreign substance.
b. It can block small bronchioles by mechanical plugging.
c. It can cause a decrease in surfactant production through lung trauma.
- Assessment

21
Newborn
a. Infants with meconium-stained amniotic fluid can have difficulty establishing respirations at
birth (those who were not born breech have had a hypoxic episode in utero to cause the
meconium to be in the amniotic fluid).
b. The Apgar score is apt to be low.
c. Almost immediately, tachypnea, retractions, and cyanosis occur.
d. After the initiation of respirations, an infant’s respiratory rate may remain elevated (tachypnea)
and coarse bronchial sounds may be heard on auscultation.
e. An infant may continue to have retractions because the inflammation of bronchi tends to trap
air in the alveoli, limiting the entrance of oxygen.
f. The air trapping may also cause enlargement of the anteroposterior diameter of the chest
(barrel chest).
g. Blood gases will reveal a poor gas exchange, evidenced by a decreased PO2 and an increased
PCO2.
h. A chest radiograph will show bilateral coarse infiltrates in the lungs, with spaces of
hyperaeration (a peculiar honeycomb effect).
i. The diaphragm will be pushed downward by the overexpanded lungs.
- Therapeutic Management
a. Amnioinfusion can be used to dilute the amount of meconium in amniotic fluid and reduce the
risk of aspiration.
b. Cesarean birth after deeply meconium-stained amniotic fluid becomes evident during labor.
c. After birth and tracheal suction, infants may need to be treated with oxygen administration and
assisted ventilation.
d. Antibiotic therapy may be used to forestall the development of pneumonia as a secondary
problem.
e. Surfactant may be administered to increase lung compliance
f. Lung tissue is fairly noncompliant after meconium aspiration, which may necessitate high
inspiratory pressure. This can cause pneumothorax or pneumomediastinum.
g. Infants must be observed closely for signs of trapping air in the alveoli, because the alveoli can
expand only so far and then will rupture, sending air into the pleural space (pneumothorax).
h. Observe an infant closely for signs of heart failure such as increased heart rate or respiratory
distress.
i. Maintain a temperature-neutral environment to prevent to prevent the infant from having to
increase metabolic oxygen demands.
j. A chest physiotherapy with percussion and vibration may be helpful to encourage the removal
of remnants of meconium from the lungs
k. Some infants may need to be administered nitric acid or maintained on ECMO to ensure
adequate oxygenation.

22
Newborn
12. Fetal Alcohol Spectrum Disorders (FASDs)

FASDs are a group of conditions caused by maternal alcohol use during pregnancy. The disorders are
a result of teratogenesis. FASDs cause cognitive and physical delays. Fetal alcohol syndrome is the
most severe of the FASDs. The other disorders included in this category are alcohol-related
neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBDs).
- Assessment
a. Facial changes
o Short palpebral fissures
o Hypoplastic philtrum
o Short, upturned nose
o Flat midface
o Thin upper lip
o Low nasal bridge
b. Abnormal palmar creases
c. Respiratory distress (apnea, cyanosis)
d. Congenital heart disorders
e. Irritability and hypersensitivity to stimuli
f. Tremors
g. Poor feeding
h. Seizures
- Interventions
a. Monitor for respiratory distress.
b. Position the newborn on the side to facilitate drainage of secretions.
c. Keep resuscitation equipment at the bedside.
d. Monitor for hypoglycemia.
e. Assess suck and swallow reflex.
f. Administer small feedings and burp well.
g. Suction as necessary.
h. Monitor intake and output.
i. Monitor weight and head circumference.
j. Decrease environmental stimuli.
k. Make referral to local early intervention system.
IV. Nursing Process
A. Assessment
All infants need to be assessed at birth for obvious congenital anomalies and gestational age
(number of weeks they remained in utero). Both determinations can be done by the nurse who first
examines an infant. Be certain these assessments are made with an infant under a prewarmed

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Newborn
radiant heat warmer to guard against heat loss. Continuing assessment of high-risk infants involves
the use of instrumentation such as cardiac, apnea, and blood pressure monitoring. However, no
matter how many monitors are used, they never replace the role of frequent, close, common-sense
observation. Carefully evaluate comments from fellow nurses that an infant “isn’t himself” or
“breathes oddly.” These comments, although not scientific, are the same observations that parents
who know their baby well report at health visits. A nurse who knows an infant well from having
cared for a baby consistently over time often senses changes before a monitor or other equipment
begins to put a quantitative measurement on the factor.
B. Nursing Diagnosis
To establish nursing diagnoses for high-risk infants, it is important to be aware of the normal
assessment parameters of newborns. Nursing diagnoses generally center on the nine priority areas
of care for any newborn:
1. Ineffective airway clearance related to presence of mucus or amniotic fluid in airway
2. Ineffective cardiovascular tissue perfusion related to breathing difficulty
3. Risk for deficient fluid volume related to insensible water loss
4. Ineffective thermoregulation related to newborn status and stress from birth weight
variation
5. Risk for imbalanced nutrition, less than body requirements related to lack of energy for
sucking
6. Risk for infection related to lowered immune response in newborn
7. Risk for impaired parenting related to illness in newborn at birth
8. Deficient diversional activity (lack of stimulation) related to illness at birth
9. Readiness for developmental care to decrease overstimulation easily caused by necessary
life-saving procedures
C. Outcome Identification and Planning
Be certain when establishing expected outcomes that they are consistent with a newborn’s
potential. A goal that implies complete recovery from a major illness, for example, may be
unrealistic for one newborn but completely appropriate for another. Plan care that is individualized
considering a newborn’s developmental as well as physiologic strengths, weaknesses, and needs.
This helps to ensure that parents as well as the health care team understand the newborn’s
particular care priorities and potential. Many families of high-risk newborns will need continued
support to care for their infants at home.
D. Implementation
Interventions for any high-risk newborn are best carried out by a consistent caregiver and should
focus on conserving the baby’s energy and providing a thermoneutral environment to prevent
exhaustion and chilling. Painful procedures should be kept to a minimum to help the infant achieve

24
Newborn
a sense of comfort and balance. Assisting parents to participate in care such as bathing or feeding
their infant may help make the child real to them for the first time and start the bonding process.
E. Outcome Evaluation
High-risk newborns need long-term follow-up so any consequences of their birth status, such as
minimal neurologic injury, can be identified and arrangements for special schooling or counseling
can be made. Examples of expected outcomes include:
1. Infant maintains a patent airway.
2. Infant tolerates all procedures without accompanying apnea.
3. Infant demonstrates growth and development appropriate for gestational age, birth weight, and
condition.
4. Infant maintains body temperature at 98.6° F (37.0° C) in open crib with one added blanket.
5. Parents visit at least once and make three telephone calls to neonatal nursery weekly.
6. Parents demonstrate positive coping skills and behaviors in response to newborn’s condition.
Integrative Activity
Watch the following videos:
1. Assessment of preterm: https://www.youtube.com/watch?v=GNqzV7LuFGE
2. SIDS: https://www.youtube.com/watch?v=kDFoGmIyShI
3. RSD: https://www.youtube.com/watch?v=QgFinYq8bYU
4. Meconium aspiration syndrome: https://www.youtube.com/watch?v=_bljvIoPZVg
5. Phototherapy https://www.youtube.com/watch?v=2Qz5Oof52Cs
References
Flagg, J. (2018). Maternal and child health nursing: Care of the childbearing and childbearing
family (8thed.). Philadelphia, PA: WoltersKluwer.
Murray S, (2014) Foundations of maternal-newborn and women’s health nursing
(6thed). St. Louis, Missouri: Elsevier Saunders.
Credits and Quality Assurance
Prepared by: Reviewed by:
MELANIE C. TAPNIO, MAN, RN JENNY ROSE LEYNES-IGNACIO, EdD, MAN, RN

Assistant Professor Assistant Professor & OBE Facilitator
Recommending Approval:
Approved by:
Noriel P. Calaguas, MSHSA, RN PRECIOUS JEAN M. MARQUEZ, PhD, MSN, RN

Assistant Professor & Chairperson, Nursing Program OIC Dean
School of Nursing and Allied Medical Science

25
Newborn

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HOLY ANGEL UNIVERSITY

School of Nursing and Allied Medical Sciences

Module 7: Nursing Care of a Family with a High-Risk Newborn

Module 7: Nursing Care of a Family with a High-Risk

12. Fetal Alcohol Disorders

Module 7: Nursing Care of a Family with a High-Risk

• Lack of prenatal care

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Dubowitz Maturity Scale

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

II. Post term infants

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

b. Elevated serum bilirubin levels

Module 7: Nursing Care of a Family with a High-Risk

j. Expect loose green stools.

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

The diagnosis of RDS is made on the clinical signs:

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

12. Fetal Alcohol Spectrum Disorders (FASDs)

Module 7: Nursing Care of a Family with a High-Risk

Module 7: Nursing Care of a Family with a High-Risk

Credits and Quality Assurance

Prepared by: Reviewed by:

MELANIE C. TAPNIO, MAN, RN JENNY ROSE LEYNES-IGNACIO, EdD, MAN, RN

Noriel P. Calaguas, MSHSA, RN PRECIOUS JEAN M. MARQUEZ, PhD, MSN, RN

Module 7: Nursing Care of a Family with a High-Risk

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