Midterms: 9N Pedia

• High-risk newborn


  A newborn, regardless of gestational age or birth weight, who has a greater-than-average chance of morbidity or mortality because of conditions or circumstances superimposed on the normal course of events associated with birth and the adjustment to extrauterine existence
• The gestational age at which survival outside the uterus is believed to be possible, or as early as 23 weeks of gestation up to 28 days after birth and includes threats to life and health that occur during the prenatal, perinatal, and postnatal periods
• Classification of high-risk newborns

  • According to birth weight
  • According to gestational age
  • According to mortality
• Mature infant


  Birth weight of 2500g (5.5 pounds) or more
• Low-birth-weight (LBW) infant


  Birth weight is less than 2500g (5.5 lbs), regardless of gestational age
• Very-low-birth-weight (VLBW) infant


  Less than 1500 g (3.3 lbs)
• Extremely low-birth-weight (ELBW) infant


  Less than 1000 g (2.2 lbs)
• Appropriate-for-gestational-age (AGA) infant


  Weight falls between the 10th and 90th percentiles on intrauterine growth curves
• Small-for-date (SFD) or small-for-gestational-age (SGA) infant


  Rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves
• Premature (Preterm) infant


  An infant born before completion of 37 weeks of gestation, regardless of birth weight
• Full-term infant


  An infant born between the beginning of 38 weeks and the completion of 42 weeks of gestation, regardless of birth weight
• Postmature (Postterm) infant


  An infant born after 42 weeks of gestational age, regardless of birth weight
• Live birth


  Birth in which the neonate manifests any heartbeat, breathes or displays voluntary movement, regardless of gestational age
• Fetal death


  Death of the fetus after 20 weeks of gestation and before delivery, with absence of any signs of life after birth
• Neonatal death


  Death that occurs in the first 27 days of life; early neonatal death occurs in the first week of life; late neonatal death occurs at 7 to 27 days
• Perinatal mortality


  Describes the total number of fetal and early neonatal deaths per 1000 live births
• Postnatal death


  Death that occurs at 28 days to 1 year after birth
• All infants needs to be assessed at birth for obvious congenital anomalies and gestational age
• Assessment is done under a prewarmed radiant heat warmer to guard against heat loss
• Equipment for assessment


  • Cardiac monitoring
  • Apnea monitoring
  • Oxygen saturation monitoring
  • Blood pressure monitoring
• Outcome identification and planning must be consistent with newborn's potential
• Individualized care considering a newborn's developmental level as well as physiologic strengths, weakness, and needs
• Families will need support to care for their infant at home and therefore may need referral to a home health care or other agency
• Implementation


  1. Consistent caregiver

  2. Focus on conserving the baby's energy

  3. Providing a thermoneutral environment to prevent exhaustion and hypothermia
• Newborns priorities in the first days of life

  • Initiation and maintenance of respirations
  • Establishment of extrauterine circulation
  • Maintenance of fluid and electrolyte balance
  • Control of body temperatures
  • Intake of adequate nourishment
  • Establishment of waste elimination
  • Prevention of infection
  • Establishment of an infant-parent/caregiver relationship
  • Institution of developmental care or care that balances physiologic needs and stimulation for best development
• Resuscitation


  1. Establish airway

  2. Expand the lungs

  3. Initiate and maintain effective ventilation
• If the respiratory system becomes severe enough that a newborn's heart begins to fail (heart rate less than 60 beats/min) despite effective pressure ventilation, resuscitation should then also include chest compressions
• If the infant does not initiate spontaneous breathing following gentle stimulation, place the infant under a radiant heat warmer in a "sniffing" position (head slightly tipped back) and rub and dry his or her back and hair again to see if this additional stimulation initiates respirations
• Airway


  • Term newborn - warming, drying, and stimulating the baby by rubbing the back is enough to initiate respiration
  • Rubber bulb syringe - used to suction infant's noses and mouths. But bradycardia can be associated with bulb suctioning, routing suctioning of the nose and mouth is no longer recommended unless there is concern that the airway is obstructed
  • An infant with Meconium stained amniotic fluid at birth but is breathing does not need suctioning to clear the airway - but if with poor muscle tone and inadequate breathing, begin the initial steps of resuscitation under the warmer
  • Positive pressure ventilation via face mask should be initiated if the newborn is not breathing or the heart rate is less than 100 bpm
  • If no spontaneous respirations after initial steps —endotracheal tube may be inserted so air can be effectively administered
• Apnea


  Pause in respirations longer than 20 seconds with bradycardia
• Lung expansion


  1. Well newborn inflate their lungs adequately independently with a first breath

  2. The sound of the baby crying loudly is proof that lung expansion is good because the vocal sounds are produced by a free flow of air over the vocal cords

  3. If an infant needs air or oxygen by bag or mask, be certain the mask covers both the mouth and the nose

  4. Be certain to listen to both Lungs to verify both lungs are being aerated

  5. Correct placement of the endotracheal tube in the trachea and not the esophagus can be confirmed by a CO2 monitor ( no CO2 will return If the tube is in the esophagus)

  6. An X-ray will confirm proper placement and depth in the trachea
• Drug therapy


  • Naloxone (Narcan) should not be routinely administered because it has little effect and may cause seizures in a newborn
  • If heart rate continues to be inadequate (less than 60 beats/min), epinephrine 1:10,000 may be administered (IV) to stimulate heart action
  • Surfactant - for preterm infants to replace the natural surfactant that has not yet formed in their lungs
• Ventilation maintenance


  1. Effective ventilation continued respirations must be maintained

  2. Pulse oximetry- increasing respiratory rate, grunting, nasal flaring —are often the first signs of obstruction or respiratory compromise in newborns— if these are present, look for intercostal retractions (inward sucking of the anterior chest wall on inspiration)
• Establishing extrauterine circulation


  1. If an infant has no audible heartbeat, or if the cardiac rate is below 60 beats/min -chest compression should be started

  2. Hold the infant with fingers encircling the chest and wrapped wound the back and depress the sternum with both thumbs on the lower third of the sternum, approximately one third of its depth (1 or 2 cm) at a rate of at least 100 times per minute ("1, 2, 3, bag!")
• Maintaining fluid and electrolyte balance

  1. Hypoglycemia- result of initial resuscitation attempt, results from the effort the newborn expended to begin breathing

  2. Dehydration - caused by insensible water loss caused by rapid respirations

  3. Infants with hypoglycemia treated with 10% dextrose in water to restore their blood glucose level

  4. Monitor fluid status by urine output and urine specific gravity. An output less than 2m/kg/hr or a specific gravity greater than 1.015 to 1.020 suggest inadequate fluid intake
• Regulating temperature


  1. Keep newborns in a neutral temperature environment, not too hot nor too cold, to maintain a minimal metabolic rate necessary for body functioning

  2. Too hot- decrease metabolism to cool their body

  3. Too cold- increase metabolism to warm body cells

  4. Kangaroo care -use of skin-to-skin contact with a parent

  5. Increased metabolism can be destructive because it calls for increased oxygen, and without oxygen available due to respiratory difficulty, body cells become
• Hypoglycemia


  Result of initial resuscitation attempt, results from the effort the newborn expended to begin breathing
• Dehydration


  Caused by insensible water loss caused by rapid respirations
• Treating infants with hypoglycemia

  Treated with 10% dextrose in water to restore their blood glucose level
• Monitoring fluid status


  1. Monitor urine output and urine specific gravity

  2. Output less than 2m/kg/hr or specific gravity greater than 1.015 to 1.020 suggest inadequate fluid intake