HIGH RISK NEWBORN
- More than 42 weeks AOG
Problems related to Maturity
 Prematurity (Preterm)
- Infant born before completion of 37th week
of pregnancy
- Earlier born -> greater complications
- RDS; difficulty in regulating body
temperature; infection; hemorrhage
Causes:
Maternal Factors
 Age
 Smoking/alcohol/substance abuse
 Poor Nutrition
 Pre-eclampsia
Factors involving Pregnancy
 Placenta previa
 Abruptio placenta (dark blood)
Factors involving Fetus
 Multiple gestations
 Infection
Characteristics:
 Less than 2500 grams
 Thin, shiny, pink or red skin ; able to see
veins
 Large head compared to body (3 cm > CC)
 Covered with vernix caseosa and lanugo
 Few or no creases on soles
 Genitalia may be small and underdeveloped
Nursing Diagnosis:
 Impaired Gas Exchange r/t immature
pulmonary functioning
 Ineffective thermoregulation r/t immaturity
Interventions:
 Control environment to maintain body
temperature (skin-to-skin contact, kangaroo
mother care, droplight)
 Control and normalize respirations
 Monitor oxygen saturation and give
appropriate oxygen
 Postmaturity (Postterm)
- Placenta loses ability to nourish the fetus
- Increases risk of fetal asphyxia which leads
to MAS
- At risk for birth injury r/t dystocia
Causes:
 Unknown
 Previous postterm birth
 Miscalculated due dates
 Irregular menstrual cycle
Characteristics:
 Dry, cracked, peeling skin
 Absence of vernix caseosa, minimal lanugo
 Abundant scalp hair
 Overgrown nails
 Creases on palms and soles
 Minimal subcutaneous fat
 Skin and cord yellow/green caused by
meconium staining
 Wasted physical appearance
Management:
 Check for respiratory problems related to
meconium aspiration
 Blood test for hypoglycemia
 Induce labor
 Assess for presence of birth injuries
Problems related to Weight/Size
 Small for Gestational Age (SGA)
- Below 10th percentile on an intrauterine
growth curve for that age
- Under 2500 g or 5 lbs
- Can be preterm, term, or postterm
- Related to intrauterine growth restriction
Causes:
Maternal Factors
 Poor nutrition
 Previous history of SGA
 Grand multiparity
 Maternal diseases (PIH, GDM)
 Smoking/tobacco/alcohol
Placental Factors
 Placenta infarcts
 Structural abnormality
 Vascular thrombosis
 Abruptio placentae
 Fetal Factors Acute Illness in the Newborn

 First born  Respiratory Distress Syndrome (RDS)

 Genetic defect
 Multiple gestations
 Intrauterine infections (Rubella)
Characteristics
 Below average in weight, length and head
circumference
 Wasted appearance
 Small liver (difficulty regulating protein,
glucose and bilirubin)
 Little scalp care
 Sunken abdomen
 Dry cord & stained yellow
Management
 Assess for presence of meconium during
labor and delivery, thoroughly suction
airway immediately after delivery if present
 Temperature controlled beds/incubators
 Assess for signs of hypoglycemia
 Weigh daily and assess changes in weight
 Large for Gestational Age (LGA)
- birth weight above 90th percentile (over
4000 g or 8 lbs)
- appears deceptively healthy but a
gestational exam will reveal immature
development
- most are born at term, few maybe preterm
or postterm
- macrosomia
Causes
 diabetic mother
 multiparous women
 gestational age, fetal sex, genetic factors,
congenital anomalies, medications
Characteristics
 with immature reflexes
 may have extensive bruising or a birth injury
(broken clavicle)
 with prominent caput succedaneum,
cephalhematoma or molding
- Infant respiratory distress syndrome
- Hyaline Membrane Disease -> comes from
exudate of fetal blood that can be seen in
the bronchioles; prevents oxygen and
carbon dioxide exchange in the alveolar
capillary membrane
- Occurs most often on preterm infants and
diabetic mothers; CS deliveries and cases
that decrease blood perfusion in the lungs
- Fetal surfactant = 7 months old (28 weeks)
which lower surface tension in the airway
and keep lung alveoli open; has immune
cells
Predispositions
 Premature infants
 CS delivery
 Infants of diabetic mothers
 Perinatal asphyxia
Onset
 Usually less than 2-5 hours after birth
 Increases in severity from 24 -48 hours
 Then, gradual improvement after 48-72
hours
Cause
 Immature surfactant production
 Usually begins at 18-20 weeks AOG
*Surfactant does not form until 34 weeks
Characteristics
 Atelectasis (lung collapse)
 Ventilation-perfusion abnormalities
 Reduced lung compliance
 Slightly more common in male (1.8:1)
Assessment
 Respiratory difficulties that get worse
 Cyanosis
 Flaring of nostrils
 Tachypnea
 Grunting sounds with breathing
 Chest retractions

Management Treatment

 Induce labor  Mechanical ventilation machine

 CS delivery  Supplemental O2 + CPAP
 Check for hypoglycemia, early feeding with  Surfactant replacement
a glucose/water solution  Maintain neutral thermal environment
 Assess for signs of birth defect due to increase O2 demand if neonate
is hypothermic
Nursing Diagnosis
Nursing Diagnosis
 Ineffective breathing pattern r/t possible
birth trauma in LGA newborn
  Impaired Gas Exchange r/t immaturity of
newborn’s lungs & lack of surfactant
 Neonatal Sepsis
- Also known as septicemia Treatment/Management
- Generalized bacterial infection in the
bloodstream - Antibiotics order by doctor
- Severe infection in newborn/infants Ampicillin 100mg/kg/dose IV q 12hrs
- Can cause death if not recognized properly Gentamicin 3.5mg/kg/dose IV q 24hrs
- No local inflammatory response - Supportive therapy
IV fluids
Early Onset Late Onset Nutritional therapy & O2
 <7 days of life  >7 days
 (85% <24hrs)
 Before delivery:  Environmental  Meconium Aspiration Syndrome (MAS)
Infected amniotic (nosocomial) - As early as 10 weeks AOG meconium is
fluid or
present in the fetal bowel
occasionally ff
maternal sepsis - Aspiration of meconium in the
 During delivery:  Coagulase tracheobronchial tree during first few
Contact with negative breaths after delivery in a term neonate
organisms in S.aureus, - Green or greenish black fluid
vagina E.coli - 10 to 12 % in all pregnancies
 After delivery:  High
exposure to incidence 3 Ways MAS could lead to RDS
organisms in - Inflammation of bronchioles
infant’s - Block small bronchioles by mechanical
environment
plugging
 Group B  Preterm baby
streptococcus, - Decrease in surfactant production
E.coli, H. Assessment
influenza, listeria,
virus, STD - APGAR score less than 6 at 1 and 5
 Low incidence  Bacteremia & minutes, immediate signs of respiratory
Meningitis distress at delivery (cyanosis, tachypnea,
 Near term, term  Indwelling respirations)
catheter, - Overdistended, barrel-shaped chest
central lines - Diminished breath sounds
and chest
- Yellow staining skin, nails and umbilical
drains
cord
 Pneumonia 
 Prolonged ROM,  Interventions
prematurity, fetal
distress, foul - Suction baby’s oropharynx after neonate’s
smelling amniotic head is born, remove as much meconium
fluid or as possible before baby’s first breath
malodorous baby - Administer O2 to maintain adequate O2Sat,
and PO2
- Incidence is four times greater in high risk - Anticipate need for mechanical ventilation
infants than normal neonates , and two - Perform chest physiotherapy routinely
times greater among males
- Risk factors: prematurity and congenital
anomalies  Hyperbilirubinemia

Prevention
Physiologic Jaundice Pathologic Jaundice
- Handwashing  After first 24hrs  Within 24hrs of
- Proper handling of formula and supplies of life (icterous life
- Breastfeeding neonatorum)
 Resolution of  Hemolytic
Diagnostic Evaluation enclosed disease of the
- Laboratory Tests hemorrhage newborn
 Infection  Rh
- Xray
Incompatibility
- Blood cultures
 Dehydration  ABO
- Urinalysis Incompatibility
- CSF  Sepsis
 *Exposure to
 early morning - Marry at the right time
sunlight - Redress medical problems in medical care
for underprivileged
- Avoid prone sleeping, sleeping on soft
surfaces and hyperthermia
Rh Incompatibility ABO Incompatibility 
 Isoimmunization  Mother blood type:  Imperforated Anus
O - Anus develops on 7th week of intrauterine
 Rh (Rhesus factor)  Fetus: A,B,AB life
 Happens when  O-A, most - Congenital disorder, incomplete
mother is Rh- , common development or absence of anus in the
father/fetus is Rh+ perineum
 4th child is severely  O-B most severe - 1 in 5000 live births
affected r/t degree - More common in males
of Rh+ RBC - May occur as an additional complication of
sensitization spinal cord disorder
 1st child is severely
- External anal canal and spine cord arise
affected
from the same tissue layer
 Start of hemolysis
upon uterine Signs and symptoms
contraction
- Failure to pass meconium in 24 to 36 hours
- Abdominal distention
Assessment - Vomitus of fecal material, at risk for
- Total serum bilirubin > 13-15mg/dl indicates aspiration pneumonia
(Normal = 5.2mg/dl) - Absent neonatal canal
- Concentrated dark urine - Presence of anal membrane
- Assess for jaundice by gently pressing on - External fistula to perineum and GU system
the sternum or forehead, in dark skinned - String of pearls malformation
infants -> assess sclera, palms, soles Management
- Enlarged liver/spleen
- Temporary colostomy
Interventions - Anal surgical incision -> postop: side lying /
- Early and frequent feedings to stimulate prone position, perform anal dilation as
peristalsis prescribed
- Phototherapy (Photo-oxidation) - Simple anastomosis of the separated bowel
- Exchange transfusions segments = if rectum ends close to the
perineum and anal sphincter is formed
*Traditional phototherapy - Complicated surgery = end of rectum is at a
*Biliblanket distance from the perineum or anal
sphincter exist only in an undeveloped form
 Sudden Infant Death Syndrome (SIDS)
- Also known as crib death Complication : continence for a lifetime due to
- Sudden Unexpected Early Neonatal Death sacral anomalies and improper surgery
(SUEND) occurs in first week of life Nursing Diagnosis
- Sudden Unexpected Infant Death (SUID)
occurs in post neonatal period 1. Imbalance nutrition , less than body
- Unknown cause (brain stem abnormalities, requirements r/t bowel obstruction and inability for
apnea) oral intake
- Peak age of incidence : 2 to 4 months 2. Impaired tissue intergrity at rectum r/t surgical
- 3rd leading cause of mortality in the US incision
Risk factors
- Young maternal age  Cleft Lip and Cleft Palate
- Maternal smoking during pregnancy - Failure of median maxillary nasal process to
- Bronchopulmonary dysplasia fuse by 5 to 8 weeks AOG
- Twins - cleft lip, congenital anomaly involving one or
- Prone sleeping position more clefts in upper lip; degree of cleft
- Soft bedding varies from a small notch to a complete
- Hyperthermia separation
Prevention of SIDS - more prevalent among boys
- types of cleft lip -> unilateral incomplete,
- Avoid smoking during pregnancy unilateral complete, bilateral complete
 - cleft palate, opening of the palate, occurs
most frequently in girls; 1 in 100 births
- types of cleft palate -> unilateral complete,
bilateral complete, incomplete cleft
Causes
- Genetic
- Maternal diet
- Work (exposure to lead)
- Drug abuse
- Deficiency in folic acid
- Viral infection
Assessment
- Sonogram
- Inspection at birth
- Depressing the newborn’s tongue with a
tongue blade
Therapeutic Management
- Surgery (cheiloplasty, 1-3mos/12-18mos.)
- Teach parents to apply elbow restraints
which will be used post-op to prevent child
from touching surgical site
- Early correction -> more normal speech and
no problem in denture
Cleft lip management -> use large, soft nipples,
Breck feeder or dropper when feeding the patient;
keep patient on supine or side lying position, never
abdomen
Cleft palate management -> maintain soft diet until
palate is healed, use cup when feeding post-op;
position px on abdomen
Nursing Diagnosis
1. Risk for imbalanced nutrition, less than body
requirements r/t feeding problems caused by cleft
lip/palate
2. Risk for ineffective airway clearance r/t oral
surgery

ESSR Method of Feeding

- Enlarge (crosscut) nipple
- Stimulate sucking
- Swallow
- Rest