Chapter 24

Acquired Disorders: not passed genetically or caused by hereditary or developmental factors;

they are obtained after birth, by a reaction to environmental influences outside of the body

 Perinatal Asphyxia occurs when pulmonary oxygenation is delayed or interrupted

o newborns who survive asphyxia at birth develop long-term problems such as
cerebral palsy, intellectual disability, and speaking, hearing, visual, and learning
disabilities
o impaired gas exchange resulting in a decrease in blood oxygen levels
(hypoxemia) and an excess of carbon dioxide (hypercarbia) or hypercapnia that
leads to metabolic acidosis
o At first tachycardia and vasoconstriction
o Once that fails hypotension, bradycardia, and eventually cardiopulmonary
arrest, heart rate falls, cyanosis develops, and the newborn becomes hypotonic
and unresponsive. Newborn resuscitation is needed to help initiate breathing in
newborns who fail to breathe spontaneously at birth.
o Nursing:
 Perinatal history for risk factors, including:
 Trauma: injury to the central or peripheral nervous system secondary
to a long or difficult labor, a precipitous birth, multiple gestation,
abnormal presentation, cephalopelvic disproportion, shoulder
dystocia, or extraction by forceps or vacuum.
 Intrauterine asphyxia: for example, fetal hypoxia secondary to
maternal hypoxia, diabetes, hypertension, anemia, cord compression,
fetal bradycardia, or meconium aspiration.
 Sepsis: acquired bacterial or viral organisms from infected amniotic
fluid, maternal infection, or direct contact while passing through the
birth canal.
 Malformation: congenital anomalies including facial or upper airway
deformities, renal anomalies, pulmonary hypoplasia, neuromuscular
disorders, esophageal atresia, or NTDs.
 Hypovolemic shock: secondary to abruptio placentae, placenta previa,
or cord rupture resulting in blood loss to the fetus.
 Medication: drugs given to mother during labor that can affect the
fetus by causing placental hypoperfusion and hypotension; use of
hypnotics, analgesics, anesthetics, narcotics administered to the
mother within 4 hours of birth, oxytocin, and street drugs during
pregnancy.
 Be alert for apnea, tachypnea, gasping respirations, grunting, nasal
flaring, or retractions
 Watch for cyanosis, and pallor
 Evaluate heart rate and note bradycardia
 Note any hypothermia
  Begin resuscitation measures until the Apgar score is above 7
 Resuscitation Essential equipment includes:
 wall suction apparatus
 oxygen source
 newborn ventilation bag
 infant warmer
 surgical blue towels
 endotracheal tubes (2 to 3 mm)
 laryngoscope
 ampules of naloxone (Narcan) with syringes and needles for
administration.
 Ventilation is frequently initiated with a manual resuscitation bag and
face mask followed by endotracheal intubation if respiratory depression
continues
 Handling and rubbing the newborn with a dry towel may be all that is
needed to stimulate breathing
 Continue resuscitation until the newborn has a pulse above 100 bpm, a
good (healthy) cry, or good breathing efforts and a pink tongue

 Transient Tachypnea of the Newborn result of a delay in clearance of fetal lung liquid
o the lungs are filled with a serous fluid because the placenta, not the lungs, is
used for nutrient and gas exchange, occurs when the liquid in the lung is
removed slowly or incompletely
o infant born by cesarean birth is at risk of having excessive pulmonary fluid as a
result of not having experienced all of the stages of labor
o Nursing
 TTN is commonly seen in newborns whose mothers have been heavily
sedated in labor or have been born via cesarean birth
 Risk Factors: prolonged labor, fetal macrosomia, inadequate initial
resuscitation, breech births, when labor and birth are rapid, infants
experiencing hypothermia, infants born before 38 weeks’ gestation,
infants born to a mother with diabetes, and maternal asthma and
smoking
 Within the first few hours of birth, observe for tachypnea, expiratory
grunting, mild intercostal retractions, decreased breath sounds due to
reduced air entry, labored breathing, nasal flaring, crackles on
auscultation, and mild cyanosis
 Respiratory Distress by 6 hours of age, with respiratory rates as high as
100 to 140 breaths per minute
 Barrel Chest or hyperextension of chest
 Chest X-Ray mild symmetric lung hyperaeration and prominent
perihilar interstitial markings and streaking
  Arterial blood gas (ABG) assessment is important to ascertain the degree
of gas exchange and acid–base balance. It typically demonstrates mild
hypoxemia, mildly elevated CO2 level, and a normal pH
 Provide adequate oxygenation via a nasal cannula or oxygen hood and
determining whether the newborn’s respiratory manifestations appear to
be resolving or persisting.
 Administer intravenous fluids and/or gavage feedings until the
respiratory rate decreases enough to allow safe oral feeding. Withhold
oral feedings until the respiratory status has improved
 As TTN resolves, the newborn’s respiratory rate declines to 60 breaths
per minute or less, cyanosis resolves as do the nasal flaring and grunting
sounds, the oxygen requirement decreases, the ABG values return to the
normal range, bilateral breath sounds demonstrate good air entry, and
the chest x-ray shows resolution of the perihilar streaking

 Respiratory Distress Syndrome a breathing disorder resulting from lung immaturity

and lack of alveolar surfactant
o Characterized by compromised lung expansion, poor gas exchange, and
ventilator failure
o The more preterm the higher the risk
o Surfactant forms a coating over the inner surface of the alveoli, reducing the
surface tension and preventing alveolar collapse at the end of expiration. In the
affected newborn, surfactant is deficient or lacking, and this deficit results in stiff
lungs and alveoli that tend to collapse, leading to diffuse atelectasis
o Hyaline membranes produce a glassy appearance in the lung membranes which
is seen on x-rays
o Nursing:
 Risk Factors: preterm birth, perinatal asphyxia regardless of gestational
age, neonatal sepsis, previous birth of an infant with RDS, cesarean birth
in the absence of preceding labor (due to the lack of thoracic squeezing),
male gender, perinatal asphyxia, cold stress, and maternal diabetes
(produces high levels of insulin which inhibit surfactant production)
 Observe the infant for expiratory grunting, shallow breathing, nasal
flaring, chest wall retractions (Fig. 24.3), see-saw respirations, and
generalized cyanosis
 Tachycardia (rates above 150 to 180), fine inspiratory crackles, and
tachypnea (rates above 60 breaths per minute)
 Use the Silverman–Anderson index assessment tool to determine the
degree of respiratory distress
 A chest x-ray reveals hypoaeration, underexpansion, and a “ground-
glass” pattern
 therapies for established RDS include conventional mechanical
ventilation, continuous positive airway pressure (CPAP), or positive end-
 expiratory pressure (PEEP) to prevent volume loss during expiration, and
surfactant therapy
 Respiratory support in the form of mechanical ventilation may also be
lifesaving, but can cause lung injury, and protocols should be directed at
avoiding mechanical ventilation where possible by using nasal CPAP or
nasal ventilation
 Expect to transfer the newborn to the neonatal intensive care unit (NICU)
soon after birth
 Anticipate the administration of surfactant replacement therapy,
prophylactically or as a rescue approach
 Continuously monitor the infant’s cardiopulmonary status via invasive or
noninvasive means (e.g., arterial lines or auscultation, respectively).
 Monitor oxygen saturation levels continuously; assess pulse oximeter
values to determine oxygen saturation levels.
 Closely monitor vital signs, acid–base status, and ABGs.
 Administer broad-spectrum antibiotics if blood cultures are positive.
 Administer sodium bicarbonate or acetate as ordered to correct
metabolic acidosis.
 Provide fluids and vasopressor agents as needed to prevent or treat
hypotension.
 Test blood glucose levels and administer dextrose as ordered for
prevention or treatment of hypoglycemia.
 Cluster caretaking activities to avoid overtaxing and compromising the
newborn.
 Place the newborn in the prone position to optimize respiratory status
and reduce stress.
 Perform gentle suctioning to remove secretions and maintain a patent
airway.
 Assess level of consciousness to identify intraventricular hemorrhage.
 Monitor x-ray studies to detect atelectasis or air leak.
 Provide a neutral thermal environment to reduce metabolic and oxygen
demands.
 Provide sufficient calories via gavage and intravenous feedings.
 Maintain adequate hydration and assess for signs of fluid overload.
 Provide information to the parents about treatment modalities; give
thorough but simple explanations about the rationales for interventions
and provide support.
 Encourage the parents to participate in care
 Complications: BPD (chronic lung disease), patent ductus arteriosus,
congestive heart failure, intraventricular hemorrhage, ROP, necrotizing
enterocolitis (NEC), complications resulting from intravenous catheter
use (infection, thrombus formation), and developmental delay or
disability
 Meconium Aspiration Syndrome newborn inhales particulate meconium mixed with
amniotic fluid into the lungs while still in utero or on taking the first breath after birth
o Meconium is sterile and does not contain bacteria, Intrauterine distress can
cause passage into the amniotic fluid
o Green-stained amniotic fluid suggests the presence of meconium in the amniotic
fluid and should be reported immediately
o Factors that promote the passage in utero include placental insufficiency,
maternal hypertension, preeclampsia, oligohydramnios, fetal hypoxia, transient
umbilical cord compression, and maternal drug abuse, especially of tobacco and
cocaine
o Aspiration induces airway obstruction, surfactant dysfunction, hypoxia, and
chemical pneumonitis with inflammation of pulmonary tissues. In severe cases, it
progresses to persistent pulmonary hypertension and death
o When aspirated into the lungs, meconium blocks the bronchioles, causing an
inflammatory reaction as well as a decrease in surfactant production
o Nursing:
 Predisposing factors for MAS include post-term pregnancy; breech,
forceps, or vacuum extraction births; nulliparity; ethnicity (Pacific
Islander, Indigenous Australian, African-American); intrapartum fever;
low Apgar score; prolonged or difficult labor associated with fetal distress
in a term or post-term newborn; birth weight of >4,500 g; Apgar score of
<8 at 5 minutes of age; maternal infection; infants delivered by cesarean
section; maternal hypertension or diabetes; oligohydramnios; fetal
growth restriction; prolapsed cord; or acute or chronic placental
insufficiency
 After birth, note any yellowish-green staining of the umbilical cord, nails,
and skin
 Observe the newborn for a barrel-shaped chest with an increased
anterior–posterior chest diameter (similar to that found in a client with
chronic obstructive pulmonary disease), prolonged tachypnea,
progression from mild to severe respiratory distress, intercostal
retractions, end-expiratory grunting, and cyanosis
 Coarse crackles and rhonchi upon auscultation
 Chest x-rays show patchy, fluffy infiltrates unevenly distributed
throughout the lungs and marked hyperaeration mixed with areas of
atelectasis.
 ABG metabolic acidosis with a low blood pH, decreased PaO2, and
increased PaCO2
 Expect to administer hyperoxygenation to dilate the pulmonary
vasculature and close the ductus arteriosus or nitric oxide inhalation to
decrease pulmonary vascular resistance, or to use high-frequency
oscillatory ventilation to increase the chance of air trapping
 Cluster newborn care to minimize oxygen demand.
 Maintain an optimal thermal environment to minimize oxygen
consumption.
 Prevent and treat any complications such as hypotension, metabolic
acidosis, or anemia.
 Administer broad-spectrum antibiotics to treat bacterial pneumonia.
 Pay careful attention to systemic blood volume and blood pressure to
decrease right-to-left shunting through the patent ductus.
 Administer sedation to reduce agitation and oxygen consumption.
 Continuously monitor the newborn’s condition—cardiac and respiratory
status, oximetry.
 Persistent Pulmonary Hypertension of the Newborn  is a cardiopulmonary disorder
characterized by marked pulmonary hypertension that causes right-to-left
extrapulmonary shunting of blood and hypoxemia
o Occur idiopathically or as a complication of perinatal asphyxia, MAS, maternal
smoking, hypocalcemia, maternal obesity, maternal asthma, pneumonia,
congenital heart defects, metabolic disorders such as hypoglycemia,
hypothermia, hypovolemia, hyperviscosity, acute hypoxia with delayed
resuscitation, sepsis, and RDS
o Hypoxemia and acidosis also occur, leading to vasoconstriction of the pulmonary
artery
o Pulmonary vascular resistance is elevated to the point that venous blood is
diverted to some degree through fetal shunts (i.e., the ductus arteriosus and
foramen ovale) into the systemic circulation, bypasses the lungs, and results in
systemic arterial hypoxemia
o Nursing:
 Newborn with persistent pulmonary hypertension demonstrates
tachypnea within 12 hours after birth
 Observe for marked cyanosis, grunting, respiratory distress with
tachypnea, and retractions
 Auscultate the heart, noting a systolic ejection harsh sound (tricuspid
insufficiency murmur)
 Measure blood pressure for hypotension resulting from both heart failure
and persistent hypoxemia
 Prepare for echocardiogram, which will reveal right-to-left shunting of
blood that confirms the diagnosis
 S/S: murmur, respiratory distress, decreased pulmonary blood flow,
hypoxia, hypercarbia, hypoglycemia, cyanosis, metabolic acidosis, and
hypotension (late sign)
 newborn is transferred to the NICU for close monitoring.
 Administer oxygen therapy as ordered via nasal cannula or with positive-
pressure ventilation
 Monitor pulseox
 newborn may exhibit uneven pulmonary ventilation, with hyperinflation
in some areas and atelectasis in others
 Goals of therapy include improving alveolar oxygenation, inducing
metabolic alkalosis by administering sodium bicarbonate, correcting
hypovolemia and hypotension with the administration of volume
replacement and vasopressors, and anticipating use of extracorporeal
membrane oxygenation when support has failed to maintain acceptable
oxygenation
 Bronchopulmonary Dysplasia/Chronic Lung Disease infants who have experienced a
lung injury resulting in the need for continued use of oxygen after the initial neonatal
period (28 days of life)
o White male infants seem to be at greatest risk for developing BPD
o Associated with surfactant deficiency, genetic predisposition, prematurity,
oxygen toxicity, pulmonary edema, lung immaturity, lung injury from mechanical
ventilation, inflammation, and fluid overload
o Strongest risk factors Low gestational age and birth weight
o Excessive oxygen use in preterm infants increases the risk of BPD
o Preterm infants may require a higher initial inspiratory oxygen concentration
than term infants
o BPD can be prevented by administering steroids to the mother in the antepartal
period and exogenous surfactant to the newborn to help reduce the risk for RDS
and its severity
o Reduce the incidence of BPD:
 Use lower target oxygen saturation levels.
 Close the patent ductus arteriosus early, either medically or surgically.
 Monitor and minimize tidal volumes on ventilators.
 Use postnatal steroid therapy judiciously.
 Stem cell therapy.
 Inspired oxygen tensions should be kept as low as possible.
 Administer the antioxidant vitamin A.
 Maintain adequate nutritional status
o Nursing:
 Risk factors: male gender, preterm birth (<32 weeks), nutritional
deficiencies, White race, pulmonary hypertension, excessive fluid intake
during the first few days of life, presence of patent ductus arteriosus,
anemia, low Apgar score, severe RDS treated with mechanical ventilation
for more than 1 week, and sepsis
 S/S: tachypnea, poor weight gain related to the increased metabolic
workload, tachycardia, sternal retractions, episodes of cyanosis, nasal
flaring, and bronchospasm with abnormal breath sounds (crackles,
rhonchi, and wheezes)
 Hypoxia, as evidenced by abnormal blood gas results, and acidosis and
hypercapnia also are noted
 Chest x-rays will show hyperinflation, infiltrates, and cardiomegaly
 Provide continuous ventilatory and oxygen support and optimal nutrition
to support growth, and administering bronchodilators, anti-inflammatory
agents, and diuretics as ordered
 Provide a high caloric intake to promote growth and to compensate for
the calories expended due to the increased work of breathing
  Instruct the family about the safe use of oxygen in the home, including
the need to notify emergency medical services and utility companies that
a technology-dependent child is living in their district.
 Retinopathy of Prematurity  potentially blinding retinal vascular eye disease that
occurs in very low birth weight and preterm infants
o Risk factors: Supplemental oxygen, birth weight, multiple births, White race,
mechanical ventilation, and gestational age
o ROP can also lead to vitreous hemorrhage and retinal detachment, which is the
major cause of visual impairment and blindness
o Predisposing factors include preterm birth, low birth weight, level of oxygen
saturation, genetics, and the severity of underlying illnesses present at birth
o ROP typically develops in both eyes secondary to an injury such as hyperoxemia
due to prolonged assistive ventilation and high oxygen exposure, acidosis, and
shock
o Prevention by minimizing the risk of preterm birth through providing quality
prenatal care and health counseling to all pregnant women
o Advanced stages, surgical intervention such as laser photocoagulation therapy or
cryotherapy can be done
o Nursing:
 exhibits no signs or symptoms
 risk factors such as substance abuse, hypertension, preeclampsia, heavy
cigarette smoking, or evidence of placental insufficiency, newborns
weighing 1,500 g or less or those born at 28 weeks’ gestation or less
 Oxygen saturation target ranges in the mid-80s to lower mid-90s are
usually safe and can reduce the severity of ROP in newborns <32 weeks’
gestation
 Cover the Isolette® with a blanket and dim the surrounding lights to
protect the newborn’s eyes
 Scheduling an ophthalmic examination for the newborn. Any newborn
with a birth weight of less than 1,500 g or born at less than 28 weeks’
gestation should be examined by a pediatric ophthalmologist within 4 to
6 weeks after birth.
 Expect to administer a mydriatic eye agent to dilate the newborn’s pupils
approximately 1 hour prior to the examination as ordered
 Newborns with ROP are at risk of developing strabismus (abnormal
alignment of the eyes), nystagmus (rapid involuntary movements of the
eyes), high myopia (eyeball stretches and becomes too long which can
lead to retinal detachment, and abnormal retinal structure
 Periventricular–Intraventricular Hemorrhage  bleeding that usually originates in the
subependymal germinal matrix region of the brain, with extension into the ventricular
system
o The tremendous physiologic stress and shock experienced by a premature infant
after birth may cause the periventricular capillaries to rupture. Bleeding occurs
initially in the immediate periventricular areas causing a periventricular
hemorrhage (PVH). If the bleeding persists, the expanding volume of blood
dissects into the adjacent lateral ventricles leading to an intraventricular
hemorrhage (IVH).
o Leads to complications that may include hydrocephalus, seizure disorders,
periventricular leukomalacia (an ischemic injury resulting from inadequate
perfusion of the white matter adjacent to the ventricles), cerebral palsy, learning
disabilities, vision or hearing deficits, language difficulties, behavioral and
personality disorders, and intellectual disability
o Nursing:
 no clinical signs may be evident
 risk factors such as acidosis, asphyxia, unstable blood pressure,
meningitis, seizures, acute blood loss, hypovolemia, respiratory distress
with mechanical ventilation, intubation, apnea, hypoxia, suctioning, use
of hyperosmolar solutions, rapid volume expansion, and activities that
involve handling
 Evaluate the newborn for an unexplained drop in hematocrit, pallor, and
poor perfusion as evidenced by respiratory distress and oxygen
desaturation
 Seizures, lethargy or changes in level of consciousness, bulging fontanel,
weak sucking, metabolic acidosis,high-pitched cry, or hypotonia/flaccidity
 Palpate the anterior fontanel for tenseness
 Assess vital signs, noting bradycardia and hypotension
 Check labs for metabolic acidosis or glucose instability
 Cranial ultrasonography to detect hemorrhage
 Prevention of preterm birth is essential in preventing periventricular–
intraventricular hemorrhage
 institute measures to prevent perinatal asphyxia and birth trauma and
provide developmental care in the NICU
 Correct anemia, acidosis, and hypotension with fluids and medications.
Administer fluids slowly to prevent fluctuations in blood pressure. Avoid
rapid volume expansion to minimize changes in cerebral blood flow
 reduce the newborn’s exposure to noxious stimuli
 Provide adequate oxygenation to promote tissue perfusion, controlled
ventilation to decrease the risk of pneumothorax
  Developmental care principles include avoiding lifting the lower
extremities above the midline with diaper changes, giving rapid fluid
boluses, and high oxygen and ventilation, as these can all increase the
chance of more cranial hemorrhage
 Necrotizing Enterocolitis disease of the bowel which can cause ischemic and necrotic
injury in the gastrointestinal tract
o This inflammatory bowel disease results in inflammation and bacterial invasion
of the bowel wall
o reduce the risk of NEC include enteral antibiotics, judicious administration of
parenteral fluids, human breast milk feedings, antenatal corticosteroids, enteral
probiotics (Lactobacillus acidophilus), and slow continuous-drip feedings
o five major pathologic mechanisms that lead to NEC: bowel hypoxic ischemia
events, perinatal stressors, an immature intestinal barrier, abnormal bacterial
colonization in the gut, and formula feeding
o During perinatal or postnatal stress, oxygen is shunted away from the gut to
more important organs such as the heart and brain. Ischemia and intestinal wall
damage occur, allowing bacteria to invade
o Nursing:
 development of feeding intolerance, abdominal distention, and bloody
stools in a preterm infant receiving enteral feedings
 As the disease worsens, the infant develops signs and symptoms of septic
shock (respiratory distress, temperature instability, lethargy,
hypotension, and oliguria)
 S/S: Cardiorespiratory baseline changes, Feeding intolerance, Abdominal
distention and tenderness. Bloody or hemoccult-positive stools, Diarrhea,
Respiratory distress, Metabolic acidosis, Temperature instability,
Decreased/ absent bowel sounds, Signs of sepsis, Lethargy. Apnea, Shock,
bile-stained emesis
 Evaluate the neonate’s abdomen for distention, tenderness, and visible
loops of bowel
 Determine residual gastric volume prior to feeding; when it is elevated,
be suspicious for NEC
 If medical treatment fails to stabilize the newborn or if free air is present
on a left lateral decubitus film (where the infant is lying down on the left
side), surgical intervention will be necessary
 Surgery for NEC usually requires the placement of a proximal
enterostomy until the anastomosis site is ready for reconnection. After
surgery, postoperative supportive care includes fluids, total parenteral
nutrition (TPN), antibiotics, and bowel rest for 10 to 14 days
 NEC is suspected, immediately stop enteral feedings until a diagnosis is
made
 Give prescribed intravenous antibiotics to prevent sepsis from the
necrotic bowel
  gastric decompression as ordered with an orogastric tube attached to low
intermittent suction
 Observe the abdomen for redness or shininess, which indicates
peritonitis.
 Manage pain by administering analgesics as ordered
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 Infant of a Diabetic Motherbaby is at high risk for numerous health-related

complications, especially hypoglycemia.
o Congenital anomalies is much greater for these newborns
o Large for gestational age (LGA) (over 4000 grams) predisposing them to
shoulder dystocia, brachial plexus injury, fracture, neonatal depression or
cesarean birth
o Or small for gestational age (SGA) suffer from intrauterine malnutrition,
Uteroplacental circulation is often impaired and leads to hypoxemia,
o Fetal macrosomia occurs in 25% to 42% of diabetic pregnancies because of
hyperinsulinemia
o Nursing :
 At birth: Full rosy cheeks with a ruddy skin color
 Short neck (some describe “no-neck” appearance)
 Buffalo hump over the nape of the neck
  Massive shoulders with a full intrascapular area
 Distended upper abdomen due to organ overgrowth
 Excessive subcutaneous fat tissue, producing fat extremities
 Assess blood glucose levels, which should remain above 40 mg/dL
 Assess the newborn for signs of hypoglycemia, including listlessness,
hypotonia, apathy, poor feeding, apneic episodes with a drop in oxygen
saturation, cyanosis, temperature instability, pallor and sweating,
tremors, irritability, and seizures.
 Assess for TTN, RDS
 Hyperinsulinemia reduces production and manufacturing an unstable
surfactant
 Check for Polycythemia
 Assess the newborn for signs of birth trauma involving the head (tense,
bulging fontanels, cephalhematoma, skull fractures, and facial nerve
paralysis), shoulders and extremities (posturing, paralysis), and skin
(bruising
 Inspect the newborn for compromised oxygenation by examining the skin
for cyanosis, pallor, mottling, and sluggish capillary refill
 Prevent hypoglycemia by providing early oral feedings with breast milk or
formula at frequent intervals (every 2 to 3 hours) help to control
glucose levels, reduce hematocrit, and promote bilirubin excretion
 Avoid cold stress, which may stimulate the metabolic rate, thereby
increasing the demand for glucose
 Monitor blood glucose levels via heel stick every hour for the first 4 hours
of life and then every 3 to 4 hours until stable
 If glucose levels are not stabilized, initiate intravenous glucose infusions
as ordered and ensure that the infusions are flowing at the prescribed
rate

 Monitor serum calcium levels for changes indicating the need for
supplementation, such as with oral or intravenous calcium gluconate
 Assess the newborn for signs of hypocalcemia, such as tremors,
jitteriness, twitching, seizures, and high-pitched cry.
 Monitor serum bilirubin levels and institute phototherapy if the newborn
is over 24 hours old.
 Administer fluid therapy as ordered to maintain adequate hydration
 Birth Trauma conditions being injuries to the scalp, injuries to the skeleton, and
fracture of the clavicle
o Risk factors: prolonged or abrupt labor, abnormal or difficult presentation,
cephalopelvic disproportion, or mechanical forces, such as forceps or vacuum
used during delivery, multiple fetus deliveries, large-for-date infants, extreme
prematurity, large fetal head, or newborns with congenital anomalies
o Nursing:
 Inspect the head for lumps, bumps, or bruises
 Assess the eyes and face for facial paralysis, observing for asymmetry of
the face with crying or appearance of the mouth being drawn to the
unaffected side
 Note any absence of or decrease in deep tendon reflexes or abnormal
positioning of extremities.
Neonatal abstinence syndrome (NAS) comprises a constellation of drug-withdrawal
symptoms that result from chronic intrauterine exposure to a variety of substances, including
opioids, barbiturates, SSRIs, alcohol, benzodiazepines, caffeine, and nicotine
o Primary treatment for NAS consists of opioid replacement therapy with either
morphine or methadone
o It manifests by central nervous system irritability, short, irregular sleep patterns,
myoclonic jerks, gastrointestinal dysfunction—excessive sucking, poor feeding,
vomiting, loose stools, poor weight gain, excessive, high-pitched crying, sleep
and feeding disturbances, increased muscle tone and tremors, seizures, and
excessive sneezing, yawning, and nasal stuffiness
o Maternal history to identify risk behaviors for substance abuse:
 Previous unexplained fetal demise
 Lack of prenatal care
 Incarceration
 Prostitution
 Cigarette smoking
 Fetal growth restriction
 Mental health disorders
 History of intimate partner violence
 History of missed prenatal appointments
 Severe mood swings
 Preterm birth
 History of sexually transmitted infections (STIs) (hepatitis C and human
immunodeficiency virus (HIV)
 Precipitous labor
 Poor nutritional status
 Abruptio placentae
 Hypertensive episodes
 History of drug abuse
o Laboratory test results (toxicology) to identify substances in mother and
newborn
o Signs of neonatal abstinence syndrome (use the “WITHDRAWAL” acronym; see
Box 24.4)
o Evidence of seizure activity and need for protective environment
o Cocaine-exposed newborns are typically fussy, irritable, and inconsolable at
times. They demonstrate poor coordination of sucking and swallowing, making
feeding time frustrating for the newborn and caregiver alike
o Urine screen signifies only recent newborn exposure to maternal use of drugs. It
can detect marijuana use up to a month earlier, cocaine use up to 96 hours
earlier, heroin use 24 to 48 hours earlier, and methadone use up to 10 days
earlier
o Frequent, small feedings that provide 150 to 250 kcal/kg per 24 hours for proper
growth of the infant undergoing significant withdrawal are preferable
o
Assess the newborn for common nonspecific signs of infection, including:
o Hypotension
o Tachycardia
o Pallor or duskiness
o Hypotonia
o Temperature instability
o Cyanosis
o Poor weight gain
o Irritability
o Seizures
o Jaundice
o Grunting
o Respiratory distress
o Nasal flaring
o Apnea and bradycardia
o Lethargy
o Rash
o Petechiae
o Hypoglycemia
o Poor feeding (lack of interest in feeding)
o Abdominal distention
 Antibiotic therapy is continued for 7 to 21 days if cultures are positive, or it is
discontinued within 72 hours if cultures are negative
 Outline and carry out measures to prevent hospital-acquired infections, such as:
o Monitor and support nutritional status.
o Feed your newborn frequently to provide added fluid, protein, and calories.
o Rock, cuddle, or hold the newborn to promote bonding when out of the lights.
o Contact your pediatrician or home health care agency with any questions or
changes, including refusing feedings, fewer than five wet diapers in one day,
vomiting of complete amounts of feeding, or elevated temperature.
o Keep appointments for follow-up laboratory testing to monitor bilirubin levels.
o Provide frequent oral care and inspections of mucous membranes.
 Risk factors that might predispose the newborn to a congenital heart defect. Risk factors
include:
o Maternal alcoholism
o Maternal diabetes mellitus
o Single-gene mutation or chromosomal disorders
o Maternal exposure to x-rays
o Maternal exposure to rubella infection
o Poor maternal nutrition during pregnancy
o Maternal age over 40
o Maternal use of amphetamines
o Genetic factors (family recurrence patterns)
o Maternal metabolic disorder of phenylketonuria
o Maternal use of anticonvulsants, estrogen, progesterone, lithium, warfarin
(Coumadin), or isotretinoin (Accutane)