Objectives:

1. Assess a high-risk newborn to determine whether safe

transition to extrauterine life has occurred.
2. Formulate nursing diagnoses related to a high-risk
newborn.
3. Identify expected outcomes for a high-risk newborn and
family.
4. Plan nursing care focused on priorities to stabilize a high-
risk newborn’s body systems.
5. Implement nursing care for a high-risk newborn such as
monitoring body temperature.
6. Evaluate expected outcomes for achievement and
effectiveness of care.
7. Integrate knowledge of the needs of a high-risk newborn
with nursing process to achieve quality maternal and child
health nursing care.
High risk newborns
 are those whose incidence of illness
(morbidity) is increased because of:
prematurity,
dysmaturity,
postmaturity,
congenital anomalies,
acquired physical problems or
birth complications.
BASIC NURSING ACTIONS
A. DETECT EARLY
B. KEEP NEWBORN WARM
Rationale: the presence of a congenital defect, acquired
injuries, & other metabolic disorders predispose the NB to
hypothermia
C. PROVIDE IMMEDIATE SUPPORTIVE
CARE
D. REPORT/REFER PROMPTLY
A. DIFFICULT RESPIRATION OR
TACHYPNEA/INCREASED RATE (over
60/min)
 The earliest sign of various problems, often
respiratory in origin;
a. Asphyxia
b. Respiratory distress
c. sepsis
B. LETHARGY, FAILURE TO SUCK
 May be due to:
a. hypoglycemia,
b. hypothermia,
c. brain damage,
d. sepsis &
e. prematurity
C. CYANOSIS (generalized or central)
 Central cyanosis that increases with crying,
sucking or activity is likely b/c of CHD

 Central cyanosis that decreases w/ crying is

likely b/c of a respiratory problem, often
upper airway (nasal) obstruction
 RATIONALE:
 The NB is an obligate nose breather b/c his
mouth is close & opens only when crying.

 So if he cries with no apparent cause, check

the nares/nostrils for secretions or for
congenital anomaly: CHOANAL ATRESIA
D. EXCESSIVE MUCUS/DROOLING
 A danger sign of congenital defect;
esophageal atresia or tracheoesophageal
atresia

 Assess for maternal polyhydramnios

 SAFETY ALERT:
 In suspected esophageal atresia, NEVER place
the NB in Trendelenburg position: instead,
elevate his head slightly

 Placing him w/ his head down can drain

gastric contents to the lungs via the fistula &
can cause respiratory distress & aspiration
pneumonia

 Maintain a slight head-up position, frequent

suctioning & NPO & refer promptly
E. SAC OR DIMPLING AT THE LOWER BACK
OVER THE LUMBAR REGION

 SAFETY ALERT
 Position the NB on his abdomen or on his side,
NEVER SUPINE; cover sac with sterile saline
soak to keep it moist
F. ABSENT OR SLUGGISH MORO REFLEX
 Brain damage
 Moro reflex is the BEST INDEX of CNS
integrity in the NB
 Its absence can signify brain damage or injury
G. TWITCHING, SEIZURES OR TREMORS
 Hypoglycemia, brain damage
 SAFETY ALERT;
 For any suspicion of head/brain injury, NEVER
position the baby w/ the head DOWN, as this
will increase ICP & cause further brain
damage.

 Prevent episodes of convulsion by gentle

handling & by decreasing environmental
stimuli
H. BILE-STAINED (GREENISH) VOMITUS
 Intestinal obstruction, intussusception,
Hirschsprung’s disease

 SAFETY ALERT:
 If there is any suspicion of GI obstruction DO
NOT FEED INFANT!

 And for any infant w/ vomiting of whatever

type, PREVENT ASPIRATION!
I. YELLOWISH DISCOLORATION OF THE
SCLERA, SKIN IN THE FIRST 24 HOURS
 Hemolytic disease or erythroblastosis fetalis

SAFETY ALERT:
 The first thing to do when the NB is
yellowish is to identify how old the NB is
 Jaundice in the first 24 hours is pathologic
 Jaundice between 2-7 days is physiologic,
due to fetal polycythemia & liver immaturity
J. MECONIUM STAINING OF SKIN & NAILS
 Chronic hypoxia (often from placental
insufficiency in post maturity) if the amniotic
fluid in cephalic presentation is meconium-
stained

 If only the amniotic fluid is meconium-stained

& the infant’s skin & nails are not greenish, it
means recent hypoxia/fetal distress
K. NO PASSAGE OF MECONIUM IN 1-2
DAYS OR EMCONIUM FROM AN
INAPPROPRIATE OPENING (FISTULA)
 Imperforate anus – the most common
congenital anomaly that is not compatible
with life
Infants at Risk for
Resuscitation
 Nonreassuring fetal heart pattern
 Meconium stained amniotic fluid and/or
acidosis detected by fetal scalp sample
 Apneic episode unresponsive to tactile
stimulation
 Inadequate ventilation
 Small for gestational age
Infants at Risk for
Resuscitation (cont’d)
 Cardiac disease diagnosed prenatally
 Other congenital abnormality diagnosed
prenatally
 Premature birth
 Infant of multiple pregnancy
 Prolonged or difficult delivery
Infants at Need for
Resuscitation
 Weak cry at birth
 Poor respiratory effort at birth
 Retractions at birth
Resuscitation methods
 Stimulation by rubbing newborn's back:
Done initially to all infants

 Use of positive pressure to inflate lungs: Used

if respirations are inadequate or have not
been initiated
Resuscitation methods
(cont’d)
 Endotracheal intubation: Used immediately
for severely premature infants, infants with
known congenital anomalies, infants who do
not respond to stimulation or positive
pressure

 Medications: Nalaxone (Narcan) may be

used to reverse effects of narcotics given to
mother prior to birth
FIGURE 31–1 Demonstration of resuscitation of an infant with bag and mask. Note that the
mask covers the nose and mouth, and the head is in a neutral position. The resuscitating bag
is placed to the side of the baby so that chest movement can be seen.
 A

FIGURE 31–2 External cardiac massage. The lower third of the sternum is compressed
with two fingertips or thumbs at a rate of 90 compressions per minute. A, The thumb method
uses the fingers to support the infant’s back and uses both thumbs to compress the sternum.
B, The two-fingers method uses the tips of two fingers of one hand to compress the sternum
and the other hand or a firm surface to support the infant’s back.
 B

FIGURE 31–2 (continued) External cardiac massage. The lower third of the sternum is
compressed with two fingertips or thumbs at a rate of 90 compressions per minute. A, The
thumb method uses the fingers to support the infant’s back and uses both thumbs to compress
the sternum. B, The two-fingers method uses the tips of two fingers of one hand to compress
the sternum and the other hand or a firm surface to support the infant’s back.