26

Nursing Care of a Family With a High-Risk

Newborn

Mr. and Mrs. Atkins are the parents of a 30-week-gestation, 2-lb baby boy born last
night after a short, 4-hour labor. Their baby took a few gasping respirations at birth
but then stopped breathing. He was resuscitated by the neonatal nurse practitioner
and respiratory therapist and then transported to the intensive care nursery. Mr.
Atkins was not present for the birth because he was out of town on business. You
notice Mrs. Atkins has not visited the intensive care nursery to see her son. She has
also refused to fill in the birth certificate because she tells you, “I don’t want to give
him our favorite name because he might die.” Mr. Atkins called early this morning
and acted more upset that the baby was born than relieved the baby was receiving
intensive care. You hear him ask his wife, “Did you do something to cause this?”
Previous chapters described the birth and care of well newborns. This chapter
adds information on the care of newborns who are ill or who are born with a
significant variation in gestational age or 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.

What type of help does the Atkins family need to better accept what has
happened to them?

KEY TER MS
acute bilirubin encephalopathy (ABE)
apnea
apparent life-threatening event (ALTE)
appropriate for gestational age (AGA)
brown fat
developmental care
dysmature
extremely-low-birth-weight (ELBW) infant
extracorporeal membrane oxygenation (ECMO)
fetal alcohol spectrum disorder

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gestational age
hemorrhagic disease of the newborn
hydrops fetalis
hyperbilirubinemia
intrauterine growth restriction (IUGR)
large for gestational age (LGA)
low–birth-weight (LBW) infant
macrosomia
ophthalmia neonatorum
periodic respirations
periventricular leukomalacia (PVL)
postterm infants
preterm infants
retinopathy of prematurity (ROP)
shoulder dystocia
small for gestational age (SGA)
term infants
very-low-birth-weight (VLBW) infant

OBJ EC TIV ES
After mastering the contents of this chapter, you should be able to:
1. Define the common classifications of high-risk infants and describe common
illnesses that occur in these classifications of newborns.
2. Identify 2020 National Health Goals related to high-risk newborns that nurses can
help the nation achieve.
3. Assess a high-risk newborn to determine whether safe transition to extrauterine life
has occurred.
4. Formulate nursing diagnoses related to a high-risk newborn and family.
5. Identify expected outcomes for a high-risk newborn and family to help parents
manage seamless transitions across differing healthcare settings.
6. Using the nursing process, plan nursing care that includes the six competencies of
Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork
& Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI),
Safety, and Informatics.
7. Implement nursing care for a high-risk newborn, such as monitoring body
temperature.
8. Evaluate expected outcomes for achievement and effectiveness of care.
9. Integrate knowledge of the needs of a high-risk newborn with the interplay of
nursing process, the six competencies of QSEN, and Family Nursing to promote
quality maternal and child health nursing care.

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During pregnancy, screening women for risk factors such as younger or older than
average maternal age, having concurrent disease conditions such as diabetes or HIV
infection, experiencing pregnancy complications such as placenta previa, or an
unhealthy maternal lifestyle such as drug abuse—all of which could lead to illness in a
newborn—is essential to identify infants who may need greater than usual care at birth
(Eken, Tuten, Ozkaya, et al., 2016; Hoppe, 2013).
Unfortunately, not all instances of high risk can be predicted during pregnancy or
birth because even a newborn from a “perfect” pregnancy may require specialized care
or may develop a problem over the first few days of life, necessitating special
interventions. Any infant, especially one who is born dysmature (a newborn whose
birth weight is inappropriately low for gestational age), whether preterm, term, or
postterm, is at risk for complications at birth or in the first few days of life. Parents need
a thorough explanation of their baby’s health because these problems may require
rehospitalization or additional follow-up at home. Because preterm birth, in particular,
has the potential for leading to high-risk newborns, several 2020 National Health Goals
directly concern preterm births (Box 26.1).

BOX 26.1
Nursing Care Planning Based on 2020 National Health Goals

A preterm birth has the potential for leading to so many complications in newborns
that several 2020 National Health Goals were written specifically concerning preterm
birth:
• Reduce low birth weight (LBW) to an incidence of no more than 7.8% of live
births and very low birth weight (VLBW) to an incidence of no more than 1.4% of
live births from baselines of 8.2% and 1.5%, respectively.
• Increase the proportion of VLBW infants born at level III hospitals or subspecialty
perinatal centers from a baseline of 76.1% to a target level of 83.7%.
• Reduce the rate of fetal and infant deaths during the perinatal period (28 weeks of
gestation to 7 days or more after birth) to 5.9 per 1,000 live births from a baseline
of 6.6 per 1,000 live births.
• Reduce the rate of deaths from sudden infant death syndrome (SIDS) to 0.5 per
1,000 live births from a baseline of 0.55 per 1,000 live births (U.S. Department of
Health and Human Services, 2010; see www.healthypeople.gov).
Nurses can help the nation achieve these goals by teaching women the symptoms of
preterm labor so that, ideally, birth can be delayed until infants reach term. Nurses
also need to be prepared for resuscitation at birth for high-risk infants and to plan
developmental care that can help prevent conditions such as apnea, intraventricular
hemorrhage, and periventricular leukomalacia.

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 Being able to predict if an infant is at high risk allows for advanced preparation so
that specialized, skilled healthcare personnel can be present at the child’s birth to
perform necessary interventions, such as resuscitating a newborn who has difficulty
establishing respirations. Immediate, skilled handling of any problems that occur may
help to save the newborn’s life and also prevent future problems, such as neurologic
disorders (Wyckoff, Aziz, Escobedo, et al., 2015).

Nursing Process Overview

ASSESSMENT
All infants need to be assessed at birth for obvious congenital anomalies and
gestational age (number of weeks the newborn remained in utero). Both
determinations can be done by the nurse who first examines an infant. Be certain such
a first assessment is done under a prewarmed radiant heat warmer to guard against
heat loss.
Continuing assessment of high-risk infants involves the use of technology and
equipment such as cardiac, apnea, oxygen saturation, and blood pressure monitoring.
Regardless of how many monitors are used, they do not replace the role of frequent,
close, common sense observations by a nurse who knows an infant well from having
cared for the baby consistently over time because such a nurse often senses changes
before a monitor or other equipment begins to put a quantitative measurement on the
change. Carefully evaluate comments from fellow nurses such as an infant “isn’t
himself” or “breathes irregularly.” These comments, although not evidence based, are
the same observations that parents who know their baby well report at healthcare
visits.
NURSING DIAGNOSIS
To establish nursing diagnoses for high-risk infants, it is important to be aware of the
usual parameters of newborns. Examples of nursing diagnoses that center on the
priority areas of care for all newborns include:
• Ineffective airway clearance related to the presence of mucus or amniotic fluid
in the airway
• Ineffective tissue oxygenation related to breathing difficulty
• Ineffective thermoregulation related to immature status
• Risk for deficient fluid volume related to insensible water loss
• Risk for imbalanced nutrition, less than body requirements, related to the lack of
strength for effective sucking
• Risk for infection related to lowered immune response due to prematurity
• Risk for impaired parenting related to illness in newborn at birth
• Deficient diversional activity (lack of stimulation) related to illness at birth
• Readiness for developmental care to decrease overstimulation easily caused by
necessary lifesaving procedures

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 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.
Be certain plans for care are individualized considering a newborn’s developmental
level as well as physiologic strengths, weaknesses, and needs. Many families of a
high-risk newborn will need support to care for their infant at home and therefore
may need a referral to a home health care or other agency. Direct patients to helpful
websites and other resources when appropriate (see Chapter 20).
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 hypothermia. Painful procedures should be
kept to a minimum to help the infant achieve a sense of comfort and balance.
Assisting parents to participate in care such as bathing or feeding their infant can help
make the child real to them for the first time and can set the stage for effective
bonding.
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:
• Infant maintains a patent airway.
• Infant demonstrates an ability to suck effectively.
• Infant tolerates procedures without accompanying apnea, bradycardia, or
oxygen desaturation.
• Infant demonstrates growth and development appropriate for gestational age,
birth weight, and condition.
• Infant maintains a body temperature of 98.6°F (37.0°C) in an open crib with one
added blanket.
• Parents visit at least once and make three telephone calls to the neonatal nursery
weekly.
• Parents demonstrate positive coping skills and behaviors in response to the
newborn’s condition and ability to care for their newborn.

Newborn Priorities in the First Days of Life

All newborns have a number of needs in the first few days of life that take priority.
They include:
1. Initiation and maintenance of respirations
2. Establishment of extrauterine circulation

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 3. Maintenance of fluid and electrolyte balance
4. Control of body temperature
5. Intake of adequate nourishment
6. Establishment of waste elimination
7. Prevention of infection
8. Establishment of an infant–parent/caregiver relationship
9. Institution of developmental care or care that balances physiologic needs and
stimulation for best development
These same needs are also the primary needs of high-risk newborns. Because of
small size or immaturity or illness, however, fulfilling these needs may require special
equipment or care measures. Not all newborns will be able to achieve full wellness
because of extreme insults to their health during pregnancy or at birth or difficulty
adjusting to extrauterine life. Indications a newborn is having difficulty making the
immediate transition from intrauterine to extrauterine life may be first apparent by a low
Apgar score rating (see Chapter 18).

INITIATING AND MAINTAINING RESPIRATIONS

Ultimately, the prognosis of a high-risk newborn depends primarily on how the first
moments of life are managed because most deaths occurring during the first 48 hours
after birth result from the newborn’s inability to establish or maintain adequate
respirations (National Vital Statistics Service [NVSS], 2011). An infant who has
difficulty accomplishing effective breathing may experience residual neurologic
morbidities as a result of cerebral hypoxia. Therefore, prompt, thorough, and immediate
care is necessary for the best outcome.
Most infants are born with some degree of respiratory acidosis. However, this initial
acidosis is rapidly corrected by the spontaneous onset of respirations. If respiratory
activity does not begin immediately, respiratory acidosis not only doesn’t improve but
also increases in amount so much that the blood pH and bicarbonate buffer system can
fail. Newborn defense mechanisms then become inadequate to reverse the process. This
means the effort to establish respirations must be started immediately after birth
because, by 2 minutes, the development of severe acidosis is already well under way
(Dani, Bresci, Berti, et al., 2013).
Any infant who sustains any degree of asphyxia in utero, such as could occur from
cord compression, maternal anesthesia, placenta previa, intrauterine growth restriction,
or premature separation of the placenta, may already be experiencing acidosis at birth
and may have difficulty before the first 2 minutes of life.
An additional concern that ineffective respirations creates is the failure of fetal
circulatory shunts, particularly the ductus arteriosus, to close. Because left-side heart
pressure is stronger than right-side pressure, blood then circulates through the patent
ductus arteriosus from the left to right or from the aorta to the pulmonary artery, thus
creating ineffective pump action in the heart. Struggling to breathe and circulate blood,
the infant is forced to use available serum glucose quickly and so may become

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hypoglycemic, compounding the initial problem even further.
For all these reasons, resuscitation is important for both infants who fail to take a
first breath and for those who have difficulty maintaining adequate respirations on their
own (Wyckoff et al., 2015). Common factors that predispose infants to respiratory
difficulty and so may require resuscitation are shown in Box 26.2.

BOX 26.2
Factors Predisposing Infants to Respiratory Difficulty in the First Few Days
of Life

Low birth weight

Intrauterine growth restriction
Maternal history of diabetes
Premature rupture of membranes
Maternal use of barbiturates or narcotics close to birth
Meconium staining
Irregularities detected by fetal heart monitor during labor
Cord prolapse
Lowered Apgar score (<7) at 1 or 5 minutes
Postmaturity (postterm)
Small for gestational age
Breech birth
Multiple birth
Chest, heart, or respiratory tract anomalies

Resuscitation
Approximately 10% of newborns require some assistance to begin breathing at birth. In
order to assure newborn resuscitation can be consistent from infant to infant and one
facility to the next, the American Academy of Pediatrics (AAP) has instituted a
Neonatal Resuscitation Program updated at intervals that lists steps and rationales for
newborn resuscitation (Sawyer, Umoren, & Gray, 2017).
Based on these recommendations, resuscitation should follow an organized process:
(a) Establish an airway, (b) expand the lungs, and (c) initiate and maintain effective
ventilation. If respiratory depression becomes so severe that a newborn’s heart begins to
fail (heart rate is less than 60 beats/min) despite effective positive pressure ventilation,
resuscitation should then also include chest compressions (Wyckoff et al., 2015).

Airway
For a well, term newborn, usually warming, drying, and stimulating the baby by rubbing
the back is enough to initiate respirations. A rubber bulb syringe is a standard piece of
equipment in most birthing rooms and was often used in the past to suction infants’

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noses and mouths, but because bradycardia can be associated with bulb suctioning,
routine suctioning of the nose and mouth is no longer recommended unless there is
concern that the airway is obstructed (Wyckoff et al., 2015).
If a newborn 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. Assess a precordial pulse over the heart and attach a
pulse oximeter to monitor oxygen saturation. It is reasonable to consider the application
of a 3-lead cardiac monitor during resuscitation to obtain an accurate heart rate quickly
(Wyckoff et al., 2015).
A newborn whose amniotic fluid was meconium stained at birth but is breathing
does not need suctioning to clear the airway. If the newborn whose amniotic fluid was
meconium stained at birth presents with poor muscle tone and inadequate breathing, it is
important to begin the initial steps of resuscitation under the warmer. Positive pressure
ventilation should be initiated immediately if the newborn is not breathing or the heart
rate is less than 100 beats/min (Wyckoff et al., 2015). In most newborns, this degree of
resuscitation will initiate responsive respirations and a strong heartbeat (over 100
beats/min). Color, muscle tone, and reflexes will all improve. Mechanical suctioning
should occur only if there is an obstruction such as a mucus plug that is interfering with
effective breathing; otherwise, it may cause bradycardia (Fig. 26.1).

Figure 26.1 Suctioning a newborn with mechanical suction controlled

by a finger valve. The suction is applied as the catheter is withdrawn.
If the catheter is rotated as it is withdrawn, the risk of traumatizing the
membrane is reduced.

An infant who still makes no effort at spontaneous respirations after these initial
steps may require insertion of an endotracheal tube to be certain the airway is not

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obstructed so air can be effectively administered. If the heart rate or oxygen saturation
levels remain low with air, oxygen may be administered to achieve a preductal oxygen
saturation close to the interquartile range measured in healthy term infants after vaginal
delivery (Wyckoff et al., 2015).
In the first few seconds of life, a newborn this severely depressed may take several
weak gasps of air and then almost immediately stop breathing; the heart rate begins to
fall. This period of halted respirations is termed primary apnea. After 1 or 2 minutes of
apnea (defined as a pause in respirations longer than 20 seconds with accompanying
bradycardia), an infant again tries to initiate respirations with a few strong gasps. Most
newborns, however, cannot maintain this effort longer than 4 or 5 minutes. After this,
the respiratory effort will become weaker again and the heart rate will fall further until
the newborn stops the gasping effort altogether. The infant then enters a period of
secondary apnea. Although usually a phenomenon that occurs after birth, both types of
apnea may occur in utero.
During the period of first gasps, resuscitation attempts are generally successful.
Once a newborn is allowed to enter a secondary apnea period, however, resuscitation
becomes difficult and may be ineffective. Because it is impossible to distinguish
between the two periods simply by observation, resuscitation must always be started as
if secondary apnea is the phase occurring.
A healthcare provider skilled in laryngoscope and endotracheal tube insertion should
be present at the birth of all infants identified as high risk so a laryngoscope can be
quickly inserted into the airway as necessary (Wyckoff et al., 2015). Laryngoscope
insertion is easy in theory; in practice, the wide variation in the size of infants’ posterior
pharynges and tracheas and the emergency conditions present under which it is
attempted, make it an often difficult procedure (Fig. 26.2).

Figure 26.2 Intubation. Place the head in a neutral position with a

towel under the shoulders. The blade of the laryngoscope is inserted to
reveal the vocal cords. An endotracheal tube for ventilation is then

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 passed into the trachea, past the laryngoscope.

Laryngoscopes are equipped with different-size blades; a size 0 or 1 should be

available for newborns. Following insertion of the laryngoscope, an endotracheal tube is
slid through the laryngoscope down into the trachea. Infants under 1,000 g need a 2.5-
mm endotracheal tube (think of a thin coffee straw); those over 3,000 g need a 4.0-mm
tube. Because preterm infants are prone to hemorrhage because of capillary fragility,
gentle care during insertion is crucial.

Lung Expansion
Once an airway has been established, a newborn’s lungs need to be expanded. Well
newborns inflate their lungs adequately independently with a first breath. 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.
If an infant needs air or oxygen by bag and mask to aid lung expansion, be certain
the mask covers both the mouth and the nose. However, it is important to make sure it
doesn’t cover the eyes because eye injury could occur from either pressure of the mask
on the eyes or from drying of the cornea from air or oxygen administration. Air (or
oxygen if needed) should be administered at a rate of 40 to 60 ventilations per minute.
To prevent unnecessary cooling or drying, the oxygen that is administered should be
both warmed (between 89.6° and 93.2°F [32° and 34°C]) and humidified (60% to 80%).
The pressure needed to open lung alveoli for the first time can be as high as 40 cm
H2O. After that, pressures of 15 to 20 cm H2O are generally adequate to continue
inflating alveoli (Wyckoff et al., 2015). The pressure from anesthesia bags is controlled
solely by the pressure a healthcare provider uses when the hand squeezes against the
bag. Other types of bags such as the self-inflating (Ambu) bag can be set with a blow-
off valve that limits the pressure in the apparatus to be certain only gentle pressure is
applied (Fig. 26.3).

Figure 26.3 Types of ventilation bags used in neonatal resuscitation.

(A) The flow-inflating (anesthesia) bag requires a compressed gas
source for inflation but is able to deliver 100% oxygen. (B) The self-
inflating (Ambu) bag remains inflated at all times and is not

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 dependent on a compressed gas source. It is limited to delivering
oxygen concentration to about 40%.

It is important not to let oxygen levels in a newborn fluctuate greatly because

fluctuation can cause bleeding from immature cranial vessels. In addition, applying
pressure above what is necessary could rupture lung alveoli. If adequate ventilation is
not achieved, however, a newborn stands little chance of survival. To be certain air is
reaching the lungs with resuscitation, monitor the newborn’s oxygen saturation with
pulse oximetry in addition to auscultating the chest for the sounds of air movement
(Wyckoff et al., 2015).
Be certain to listen to both lungs to verify both lungs are being aerated. If air can be
heard on only one side or sounds are not symmetric, the endotracheal tube is probably at
or below the bifurcation of the trachea (where the trachea splits into the left and right
main-stem bronchi) and the tube is likely blocking the air from entering one of the
main-stem bronchi. Pulling the tube back half a centimeter will usually allow oxygen to
flow to both lungs. 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) immediately after insertion. An X-ray will confirm proper placement and
depth in the trachea.
When air is given under pressure to a newborn this way, the stomach also quickly
fills with air. If the resuscitation has continued for over 2 minutes, insert an orogastric
tube (through the mouth to the stomach instead of through the nose to the stomach
because babies are obligate nose breathers). Leaving the distal end open helps deflate
the stomach, which allows for better ventilation of the lungs and decreases the
possibility that vomiting and aspiration of stomach contents from overdistention will
occur.

Drug Therapy
Few medications are necessary for newborn resuscitation. Even if an infant’s respiratory
depression appears to be related to the administration of a narcotic such as morphine or
meperidine (Demerol) to the mother during labor, naloxone (Narcan), a drug to reverse
the action of narcotics, should not be routinely administered because it has little effect
and may cause seizures in a newborn (Leone, Finer, & Rich, 2012). Instead,
resuscitation efforts should focus on effective ventilation and airway support for the
persistently apneic newborn (Wyckoff et al., 2015). If heart rate continues to be
inadequate (less than 60 beats/min), epinephrine 1:10,000 may be administered
intravenously (IV) to stimulate heart action. Preterm infants may receive surfactant to
replace the natural surfactant that has not yet formed in their lungs.

Ventilation Maintenance
To allow a newborn to adjust to and maintain the cardiovascular changes that occur at

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birth, effective ventilation (continued respirations) must be maintained. Healthy
newborns accomplish this task on their own. Those who have difficulty establishing
respirations at birth need to be carefully observed in the first few hours after birth to be
certain respirations are maintained. Use of pulse oximetry is crucial to be certain oxygen
saturation remains adequate; infants this young do not have dramatic skin color changes
as do older infants and can be mildly hypoxic (low in oxygen) without becoming
cyanotic.
A steadily increasing respiratory rate, grunting, and nasal flaring are often the first
signs of obstruction or respiratory compromise in newborns. If these are present,
undress the baby’s chest and look for intercostal retractions (inward sucking of the
anterior chest wall on inspiration). Pulling in the chest muscle this way reflects the
degree of difficulty the newborn is having in breathing in air (tugging so hard to inflate
the lungs that the anterior chest muscles are pulled inward).
Place a newborn who is having difficulty with maintaining respirations under an
infant radiant warmer to help prevent cooling and acidosis; under a warmer, the clothing
(except diaper) should be removed to promote better respiration and observation while
keeping the newborn warm. Positioning an infant on the back with the head of the
mattress elevated approximately 15 degrees can also help because it allows the
abdominal contents to fall away from the diaphragm, thus increasing breathing space.
If secretions accumulating in the respiratory tract appear to be creating ineffective
breaths, an infant may need additional suctioning. “Bagging” the infant with a mask and
positive-pressure ventilation bag for a minute before suctioning will usually improve the
infant’s oxygen level and prevent it from desaturating to dangerous levels during
suctioning. As a final step, the cause of the respiratory distress must be determined and
appropriate interventions must be undertaken to correct the difficulty (see Chapter 40).

ESTABLISHING EXTRAUTERINE CIRCULATION

Although establishing respirations is the first priority at a high-risk infant’s birth, lack
of cardiac function may be present concurrently or may develop if respiratory function
cannot be quickly initiated and maintained. If an infant has no audible heartbeat, or if
the cardiac rate is below 60 beats/min, chest compressions should be started. Hold the
infant with fingers encircling the chest and wrapped around 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 (Wyckoff et al., 2015).
Lung ventilation at a rate of 30 times per minute should be coordinated with chest
compressions at a rate of 90 compressions per minute at a ratio of three compressions to
one ventilation. If a newborn’s heart rate is greater than 60 but less than 100 beats/min,
chest compressions can be stopped but ventilations should be continued. Ensuring
adequate ventilation is the major priority and should continue until the heart rate is
greater than 100 beats/min.
Continue to monitor pulse oximetry to evaluate respiratory function and cardiac
efficiency. If the pressure and the rate of chest compressions used are adequate, it

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should be possible, in addition, to palpate a femoral pulse. If the heartbeat is not above
60 beats/min after at least 30 seconds of coordinated positive-pressure ventilation and
chest compressions, intravenous epinephrine to stimulate heart action may be prescribed
(Wyckoff et al., 2015). Following cardiopulmonary resuscitation, newborns should be
transferred to a transitional or high-risk nursery for continuous cardiorespiratory
observation and care to be certain cardiac function is maintained.

MAINTAINING FLUID AND ELECTROLYTE BALANCE

After an initial resuscitation attempt, hypoglycemia (decreased blood glucose) often
results from the effort the newborn expended to begin breathing. Dehydration may also
result from increased insensible water loss caused by rapid respirations. Infants with
hypoglycemia are treated initially with intravenous 10% dextrose in water to restore
their blood glucose level. Fluids such as a dilute mixture of saline and dextrose in water
are commonly used to maintain glucose and fluid levels and electrolytes. Sodium,
additional glucose, and potassium are added as needed according to electrolyte
laboratory results.
Be certain to monitor the rate of fluid administration conscientiously in high-risk
newborns because a high fluid intake can lead to fluid overload, resulting in a patent
ductus arteriosus or heart failure. When using a radiant warmer, remember there is a
tendency for water loss from either convection or radiation. A newborn on a warmer,
therefore, may require more fluid than if he or she were placed in a double-walled
incubator.
Monitor fluid status both by urine output and urine specific gravity values. An
output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests
inadequate fluid intake.
If hypovolemia is present immediately after birth, the cause is usually fetal blood
loss from a condition such as placenta previa (see Chapter 21) or twin-to-twin
transfusion. With hypovolemia, typically tachypnea, pallor, tachycardia, decreased
arterial blood pressure, decreased central venous pressure, and decreased tissue
perfusion of peripheral tissue, with a progressively developing metabolic acidosis, will
develop. The hematocrit may be normal for some time after acute blood loss, however,
because blood cells present are in proportion to plasma. An isotonic solution (usually
normal saline) may be administered to increase blood volume. A vasopressor such as
dopamine may be given to increase blood pressure and improve cell perfusion.

REGULATING TEMPERATURE
All high-risk infants may have difficulty maintaining temperature because, in addition
to stress from an illness or immaturity, the infant’s body is often exposed for long
periods during procedures such as resuscitation.
It’s important to keep newborns in a neutral-temperature environment, one that is
neither too hot nor too cold because doing so places less demand on them to maintain a

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minimal metabolic rate necessary for effective body functioning. If their environment
becomes too hot, they are forced to decrease metabolism to cool their body. If it
becomes too cold, they must increase their metabolism to warm body cells. Increased
metabolism can be destructive because it calls for increased oxygen, and without this
oxygen available because of respiratory difficulty, body cells become hypoxic. To spare
oxygen for essential body functions, vasoconstriction of peripheral blood vessels occurs
so blood can be pushed into the central torso. If this process continues for too long a
time, pulmonary vessels constrict and pulmonary perfusion decreases. The infant’s Po2
level will fall and Pco2 will increase. As mentioned previously, a lowered Po2 level
causes fetal shunts such as the ductus arteriosus to remain open. Surfactant production
in the lungs can halt as well, further interfering with lung function. To supply glucose to
maintain increased metabolism, an infant has to resort to anaerobic glycolysis, which
pours acid into the bloodstream. As the infant becomes more and more acidotic, the risk
of acute bilirubin encephalopathy or kernicterus (the accumulation of unconjugated
bilirubin into brain cells) increases as more bilirubin-binding sites are lost and more
bilirubin is free to pass out of the bloodstream in brain cells. In short, because of
becoming chilled, heart action, breathing, electrolytic balance, and possibly brain
function all become compromised.
In addition to covering the newborn with an infant cap, wiping the body and head
dry with a towel or blanket, and using a radiant warmer or prewarmed incubator (Fig.
26.4), suggest skin-to-skin contact with one of the parents. Additional measures that can
be used to ensure the infant’s temperature stays between 36.5°C and 37.5°C (97.8°F and
99.5°F) axillary are plastic wrap, increasing the room temperature, and warmed
mattresses (Wyckoff et al., 2015). To prevent heat loss, be certain during any procedure
that the infant is not placed on a cool X-ray table or scale.

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 Figure 26.4 A neutral thermal environment. (A) A neonate in an
intensive care bed with overhead radiant warmer can be examined
periodically with ease. (B) Use of an incubator allows maintenance of
a neutral thermal environment for neonates not requiring minute-to-
minute interventions.

Radiant Heat Sources

Radiant heat warmers are open beds that have an attached overhead source of radiant
heat and provide both warmth and visibility for observation. Such units have small
probes, covered by a small shield, often silver metallic, which when placed on the
baby’s skin, register the baby’s temperature. Abdominal skin temperature, when
measured this way, should be 95.9° to 97.7°F (35.5° to 36.5°C). If an infant’s
temperature falls below this level, an alarm on the unit can be set to sound. Be certain,
with the infant laying on his or her back, you tape the probe or disk onto the infant’s
abdomen between the umbilicus and the xiphoid process. Do not tape it on the
underside of an infant or it will register a falsely high reading. Be certain as well it is
not over the liver because the heat generated by the liver can lead to false high readings
or over the rib cage where the thin subcutaneous tissue and ribs are also apt to yield an
inaccurate reading. When performing care or leaning over the infant, be careful your
head does not block the heat from the overhead source so it no longer reaches the baby.
An additional warming pad placed under an infant may be necessary for very preterm
infants or for lengthy procedures to maintain body heat.

Incubators
Newborns needing both warmth and visual observation may also be cared for in
incubators. By placing the baby in such a steady, warm environment, the need for
clothing can be eliminated, so the observation for any respiratory difficulty, possible
color changes, or unusual movements (such as seizures) can be readily observed. The
temperature of incubators varies with the amount of time portholes remain open and the
temperature of the area in which the incubator is placed. Placing one in direct sunlight
or near a warm radiator, for example, can increase the internal temperature markedly.
Placing it near a cold window can decrease the temperature. For these reasons, a
newborn’s temperature must be assessed at frequent intervals when in an incubator to be
certain the temperature level designated is being maintained. Use of an additional
acrylic shield inside the incubator helps prevent radiation and convection heat loss when
portholes are opened and may be necessary for very immature infants.
Similar to radiant warmers, some incubators have servo control mechanism units
that monitor the infant’s temperature once the probe is placed on their abdomen and
automatically changes the temperature of the incubator as needed. Portholes must
remain closed to keep the servo control operating efficiently.
As infants become both medically stabile and old enough to maintain a steady body

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temperature, they can be weaned from an incubator. Dress the infant as if he or she were
going to be in a bassinet and then set the incubator about 2°F (1.2°C) below the infant’s
temperature. After a half hour, assess whether the infant is able to maintain body
temperature. If so, lower the incubator temperature another 2°F and continue until room
temperature is reached. If an infant cannot maintain adequate temperature as the
incubator temperature level is lowered, it suggests the infant is not yet ready for room-
temperature air, and the weaning process should be slowed or stopped until the baby is
more mature or better able to self-regulate temperature.

Skin-to-Skin Care
Originally referred to as kangaroo care, skin-to-skin care is the use of skin-to-skin
contact with a parent to maintain body heat. Provide a quiet setting with lights dimmed.
Undress the infant except for a diaper and a cap. Assist the parent to sit comfortably in a
chair and hold the infant snugly against his or her unclothed chest, skin to skin. Place a
blanket over the infant for added warmth. This method of care not only supplies heat
but also encourages parent–child bonding (Moore, Anderson, Bergman, et al., 2012).

QSEN Checkpoint Question 26.1

Evidence-Based Practice
A review of the literature was completed to examine interventions that prevent
hypothermia in the premature newborn in the delivery room and that maintain core
body temperature. In addition to the use of the standard thermoregulation
interventions such as knit hats, the literature showed using respiratory gases during
ventilation, the use of gel thermal mattresses, and the use of polyethylene wraps or
bags (Fawcett, 2014). Based on the previous study, which response by Mrs. Atkins,
whose infant was born prematurely, would alert the nurse she may need further
teaching?
a. “Holding my baby directly on my chest will help with warmth and
temperature stability.”
b. “I like singing to him and notice that helps his temperature stay even.”
c. “I’ll use this adorable little hat I was given to help him stay warm.”
d. “I’m afraid he’ll suffocate if he sleeps on a warmed mattress.”
Look in Appendix A for the best answer and rationale.

ESTABLISHING ADEQUATE NUTRITIONAL INTAKE

Infants who experienced severe asphyxia at birth usually receive intravenous fluids so
they do not become exhausted from sucking or until necrotizing enterocolitis has been
ruled out, which can result when there is a temporary reduction of oxygen to the bowel
(see Chapter 45 for a discussion of necrotizing enterocolitis). If an infant’s respiratory
rate remains so rapid that the infant cannot suck effectively, gavage feedings may be

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introduced (Fig. 26.5). Others with a long-term nutrition concern may have gastrostomy
tubes placed. Preterm infants should be fed breast milk if at all possible because of the
immune protection this offers (Lee, Martin-Anderson, Lyndon, et al., 2013; Martin,
Ling, & Blackburn, 2016). If breastfeeding is not possible because the infant is too
immature to suck effectively, a mother can manually express breast milk or use a breast
pump to initiate and continue her milk supply until the time the infant is mature enough
or otherwise ready to breast feed. Her expressed breast milk can then be used in the
infant’s gavage feeding (Martin et al., 2016). Be certain when bottled breast milk is
supplied by the mother that it is well marked with the infant’s name, date and time it
was pumped, and medical record number or breast milk errors can occur the same as
medication errors (Centers for Disease Control and Prevention [CDC], 2016). It should
be stored in polycarbonate- (bisphenol A) free plastic bags or bottles, which can leech
into stored milk and possibly lead to endocrine disruptions (Trasande, 2014).

Figure 26.5 Infants who are ill at birth often need supplemental
feedings by nasogastric or gastrostomy tube.

Preterm infants reveal hunger by the same signs as term infants, such as rooting,
crying, and sucking motions. All babies who are gavage or gastrostomy fed need oral
stimulation from nonnutritive sucking and so seem to enjoy a pacifier at feeding times.
In immature infants, this may actually help them develop an effective sucking reflex. In
mature infants, pacifier use has also been shown to be a deterrent to sudden infant death
syndrome (Alm, Wennergren, Möllborg, et al., 2016). Exceptions to pacifier use are for
infants too immature to have a sucking reflex; infants who must not swallow air, such as
those with a tracheoesophageal fistula awaiting surgery; or infants mature enough to
breastfeed. The techniques of gavage feeding and gastrostomy feeding are both
discussed in Chapter 37.

ESTABLISHING WASTE ELIMINATION

Although most immature infants void within 24 hours of birth, they may void later than
term newborns because, as a result of all the procedures for resuscitation, their blood

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pressure may not be adequate to optimally supply their kidneys. Carefully document
any voidings that occur during resuscitation because this is proof that hypotension is
improving and the kidneys are being perfused. Immature infants also may pass stool
later than the term infant because meconium has not yet reached the end of the intestine
at birth.

PREVENTING INFECTIONS
Infections in high-risk newborns may occur from prenatal, perinatal, or postnatal causes.
In some instances, such as preterm premature rupture of the membranes, the risk of
adverse neurodevelopmental outcomes from the infection is what places the infant in a
high-risk category (Committee on Practice Bulletins-Obstetrics, 2016). Contracting an
infection has the potential to drastically complicate a high-risk newborn’s ability to
adjust to extrauterine life, another reason breastfeeding is good for such infants because,
beginning with colostrum, it supplies important immune protection (Verardo, Gómez-
Caravaca, Arráez-Román, et al., 2017). Infection, like chilling, has the detrimental
effect of increasing metabolic oxygen demands as well as stressing an immature
immune system, thus lowering defense mechanism protection.
Common viruses that affect infants during intrauterine life are cytomegalovirus and
toxoplasmosis virus. An infant born after contracting either of these infections may be
born with congenital anomalies from the virus invasion (see Chapter 12). The most
prevalent perinatal infections are those contracted from the vaginal canal during birth
such as herpes simplex 2 and hepatitis B. Early-onset sepsis is most commonly caused
by group B streptococcus, Escherichia coli, Klebsiella (a gram-negative rod that causes
pneumonia), and Listeria monocytogenes (a gram-positive bacteria associated with
nausea, vomiting, and possibly meningitis). Late-onset, or hospital-acquired, infections
are more commonly caused by Staphylococcus aureus, Enterobacter, and Candida.
Late-onset infections are probably most commonly spread to newborns from healthcare
personnel, which is the reason all persons coming in contact with or caring for infants
must observe good hand washing techniques and standard precautions to reduce the risk
of infection transmission. Healthcare personnel with infections have a professional and
moral obligation to refrain from caring for newborns or wear protective measures such
as a face mask to avoid spreading infections.

ESTABLISHING PARENT–INFANT BONDING

It is helpful if all women who are diagnosed as having a high-risk pregnancy are offered
a tour of a neonatal intensive care unit (NICU) during pregnancy, so if their infant
should be admitted to a NICU, they will be more comfortable in the high-tech
environment.
Be certain the parents of a high-risk newborn are kept informed of what is
happening during resuscitation at birth. They should be able to visit the special nursing
unit where the infant is admitted as soon as possible and as often as they choose, and,

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after washing their hands and in some situations wearing a gown, hold and touch their
infant, both of which are actions that help make the infant’s birth more real to them.
Should an infant not survive an initial illness, these interactions can also help make the
death more real and can help parents work through their feelings to accept this event.
Most parents handle newborn babies tentatively until they have “claimed” them or
have become firmly acquainted. If an infant was ill at birth, it may take days or weeks
before the parents are able to handle their baby comfortably and confidently because of
the number of tubes involved in care and their fear of doing something that could hurt
the infant. Urge parents to spend as much time with their infant in the intensive care
nursery as possible, especially as the infant is improving and is able to begin interacting
with them. Be certain parents have continuing access to healthcare personnel after
discharge so they can care confidently for the infant at home.
If an infant dies despite newborn resuscitation attempts, parents need to see the
infant when no longer attached to equipment. Viewing the baby can help reassure them
the baby was a perfect newborn in every other way except lung function or whatever
was the infant’s specific fatal disorder. Believing this is one way they may be able to
develop confidence to plan for other children or simply to continue their lives after such
a devastating experience.

ANTICIPATING DEVELOPMENTAL NEEDS

High-risk newborns need special care to ensure the amount of pain they experience
during procedures is limited to the least amount possible and that they also receive
adequate stimulation for growth. Most high-risk infants experience “catch-up” growth
once they stabilize from the trauma of birth or whatever caused them to be considered
high risk. They quickly move to playing with age-appropriate toys and interacting with
parents. Some parents may need support before and after their infant is discharged home
so they can begin to view their child as well and capable of doing all the things the
infant is now capable of doing. Discussing usual growth and development of infants can
help prepare them and look forward to the next developmental step.

Follow-Up of the High-Risk Infant at Home

Each time parents visit a special/intensive care nursery, assess their level of knowledge
about their child’s condition and development. For parents whose child has a complex
concern, additional education and referral to a home care agency may be necessary to
help them continue with the level of care required when the infant is discharged home
(see Chapter 4). Before discharge, the safety of their home for the care of an infant that
has healthcare needs (physical or developmental) should be evaluated. Transporting a
preterm infant in a car, for example, will require special measures, including a
commercial head support because a very small infant does not fit securely into a
standard infant car seat.
Although not well documented regarding when or why it occurs, some preterm

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infants experience episodes of oxygen desaturation, apnea, or bradycardia when seated
in standard car safety seats (Davis, 2015). To detect if this will occur, the AAP
recommends all preterm infants be assessed for cardiorespiratory stability in their car
seat prior to discharge from the healthcare facility—the “car seat challenge” (AAP,
2012).

High-Risk Infants and Child Maltreatment

When a child is born ill or preterm, the expected reaction of parents would be to protect
the infant even more than the healthy infant so no further harm could occur. In actuality,
particularly in reference to the preterm infant, the opposite may occur. Probably related
to the feeling they are “different” or because they were separated from the parents for a
long time following birth, the preterm infant may be at an increased risk for
maltreatment (see Chapter 55) (Nandyal, Owora, Risch, et al., 2013).

What If . . . 26.1
The nurse hears Mr. Atkins repeat the question he first asked his wife when
he heard his baby had been born prematurely, “What did you do to cause
this?” Would the nurse try to intervene or allow the Atkins to work out their
feelings as a couple?

The Newborn at Risk Because of Altered Gestational Age

or Birth Weight
Infants need to be evaluated as soon as possible after birth to determine their weight,
height, head circumference, and gestational age to determine their immediate healthcare
needs and to help anticipate possible future problems. Birth weight is normally plotted
on a growth chart such as the Colorado (Lubchenco) Intrauterine Growth Chart, a
special chart for newborns (available at http://thePoint.lww.com/Flagg8e).
Term infants 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). Approximately
90% of all live births fall into this category. Infants born before term (before the
beginning of the 38th week of pregnancy) are classified as preterm infants regardless
of their birth weight (Quinn, Munoz, Gonik, et al., 2016). Infants born after the end of
week 41 of pregnancy are classified as postterm infants or postmature (Blencowe,
Cousens, Oestergaard, et al., 2012).
Normally, birth weight increases for each additional gestational week of age. Infants
who fall between the 10th and 90th percentiles of weight for their gestational age,
whether they are preterm, term, or postterm, 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

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percentile in weight are considered large for gestational age (LGA). Other terms used
include:
• Low–birth-weight (LBW) infant: one weighing less than 2,500 g at birth
• Very-low-birth-weight (VLBW) infant: one weighing less than 1500 g at birth
• Extremely-low-birth-weight (ELBW) infant: one weighing less than 1,000 g at
birth
Infants in all of these classifications have immediate needs that are different from or
that are more pronounced than the needs of AGA term newborns. Each of these
categories also carries its own set of potential risks.

THE PRETERM INFANT

A preterm infant is traditionally defined as a live-born infant born before the end of
week 37 of gestation. In terms of the degree of care needed, they are further divided into
late preterm (born between 34 and 37 weeks) and early preterm (born between 24 and
34 weeks). Neonatal assessments such as inspection for sole creases, skull firmness, ear
cartilage, and neurologic development plus the mother’s report of the date of her last
menstrual period along with a sonographic estimation of age all can be helpful to
determine gestational age. Preterm birth occurs in approximately 11% of live births
worldwide, with the United States having one of the highest rates of preterm births
(Blencowe et al., 2012).
Most preterm infants need intensive care from the moment of birth to give them
their best chance of survival without neurologic aftereffects because they are more
prone than others to hypoglycemia and intracranial hemorrhage. Lack of lung
surfactant, because this does not form until about the 34th week of pregnancy, makes
them extremely vulnerable to respiratory distress syndrome (Landry & Menzies, 2011).
No matter what their weight, the initial assessment needs to differentiate healthy
preterm babies from SGA babies (who also may have a low birth weight but have more
possibility of being unhealthy and so require more help to adjust to extrauterine life). In
contrast to an SGA infant, a preterm infant appears immature and has a low birth weight
but is well proportioned for age because the baby appears to have been doing well in
utero. For an unexplained reason, however, the trigger that initiates labor was activated
too early and birth resulted even though the baby was not yet mature. Characteristics of
SGA and preterm infants are compared in Table 26.1.

TABLE 26.1 Contrasts Between Small-For-Gestational-Age and Preterm Infants

Characteristic Small-for-Gestational-Age Preterm Infant
Infant
Gestational age 24–44 wk <37 wk
Birth weight <10th percentile Normal for age
Congenital Strong possibility Possibility
malformations

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Pulmonary Meconium aspiration, Respiratory distress syndrome
problems most pulmonary hemorrhage,
apt to occur pneumothorax
Hyperbilirubinemia Possibility Very strong possibility
Hypoglycemia Very strong possibility Possibility
Intracranial Strong possibility Possibility
hemorrhage
Apnea episodes Possibility Very strong possibility
Feeding problems Most likely because of Small stomach capacity;
accompanying problem such immature sucking reflex
as hypoglycemia
Weight gain in Rapid Slow
nursery
Future restricted Possibly always be <10th Not likely to be restricted in
growth percentile because of poor growth because “catch-up”
organ development growth occurs

Etiology
At least 50% of neonatal deaths are preterm (Blencowe, Cousens, Chou, et al., 2013).
Infant mortality could be reduced dramatically if the causes of preterm birth could be
discovered and corrected and all pregnancies could be brought to term. However, even
with the examples of possible causes listed in the following, the exact cause of
premature labor and early birth is rarely exactly known.
Box 26.3 summarizes factors associated with preterm birth. Important among these
is a high correlation between low socioeconomic level and early birth. In women from
middle and upper socioeconomic groups, for example, only 4% to 8% of pregnancies
are not carried to term. In women from low socioeconomic levels, as many as 10% to
20% end before term (Joseph, Fahey, Shankardass, et al., 2014). Risk factors associated
with preterm birth include inadequate nutrition and smoking or alcohol use. The
increasing use of assisted fertility methods that result in multiple births, such as in vitro
fertilization, is another reason preterm births can occur because more multiple
pregnancies result in preterm birth than term pregnancies (Blencowe et al., 2013).
Iatrogenic (health-care–caused) issues, such as elective cesarean birth or inducing labor
before 39 weeks of pregnancy (which is not recommended but sometimes necessary
because of maternal illness or fetal reasons), also result in early births.

BOX 26.3
Common Factors Associated With Preterm Birth

• Low socioeconomic level

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 • Poor nutritional status
• Lack of prenatal care
• Multiple pregnancy
• Previous early birth
• Race (non-Whites have a higher incidence of prematurity than Whites)
• Cigarette smoking
• Age of the mother (highest incidence is in mothers younger than age 20 years)
• Order of birth (early birth is highest in first pregnancies and in those beyond the
fourth pregnancy)
• Closely spaced pregnancies
• Abnormalities of the mother’s reproductive system, such as intrauterine septum
• Infections (especially urinary tract infections)
• Pregnancy complications, such as premature rupture of membranes or premature
separation of the placenta
• Early induction of labor
• Elective cesarean birth

Assessment
Although a detailed pregnancy history may sometimes reveal the reason for a preterm
birth, the pregnancy history is often normal up to the beginning of labor. When
interviewing parents of a preterm infant, be careful not to convey disapproval of
reported pregnancy behaviors such as cigarette smoking that may have contributed to
preterm birth. Once an infant is born, a new mother needs a high level of self-esteem
and all of her inner resources to sustain her through this crisis and not be burdened by
guilt over what should or could have been. An accurate but comforting answer to a
direct inquiry about why preterm birth occurs is, “No one really knows what causes
prematurity.”
Observing a number of physical findings and reflex testing is used to differentiate
between term and preterm newborns at birth (Figs. 26.6 and 26.7). On gross inspection,
a preterm infant’s head appears disproportionately large (≥3 cm greater than chest size).
The skin is generally unusually ruddy because there is so little subcutaneous fat beneath
it, making veins easily noticeable; a high degree of acrocyanosis may be present.
Newborns delivered at greater than 28 weeks of gestation are typically covered with
vernix caseosa. In very preterm newborns, however (less than 28 weeks of gestation),
the vernix will be lacking. Lanugo is usually scant the same way in very low gestation
infants but will be extensive, covering the back, forearms, forehead, and sides of the
face in late preterm babies. Both anterior and posterior fontanelles will be small. There
are few or no creases on the soles of the feet (Visscher & Narendran, 2014).

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Figure 26.6 An immature newborn at birth. (Photodisc/PunchStock.)

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 Figure 26.7 Examples of physical examination findings and reflex
tests 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. (© Caroline Brown, RNC, MS, DEd.)

The eyes of most preterm infants appear small in relation to term infants. Although
difficult to elicit, a pupillary reaction is present. An ophthalmoscopic examination is
extremely difficult and often uninformative because the vitreous humor may be hazy. A
preterm infant has varying degrees of myopia (nearsightedness) because of a lack of eye
globe depth.
The ears appear large in relation to the head. The cartilage of the ear is immature
and allows the pinna to fall forward. The level of the ears should be carefully inspected
to rule out chromosomal abnormalities (see Chapter 8).
Neurologic function in the preterm infant is often difficult to evaluate because the

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neurologic system is still immature. Observing the infant make spontaneous or
provoked muscle movements can be as important as formal reflex testing. If they are
tested, reflexes such as sucking with coordinated swallowing and breathing will be
absent if an infant’s age is below 33 weeks; deep tendon reflexes such as the Achilles
tendon reflex will also be markedly diminished. During an examination, a preterm
infant is much less active than a mature infant and rarely cries. If the infant does cry, the
cry is weak and high pitched.
Laboratory values for a preterm infant are compared with those of the term infant at
http://thePoint.lww.com/Flagg8e.

Potential Complications
Because of immaturity, preterm infants are prone to several specific conditions.

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. Anemia
occurs from a combination of immaturity of the hematopoietic system (the effective
production of red cells with an elevated reticulocyte count may not begin until 32 weeks
of pregnancy) combined with the destruction of red blood cells because of low levels of
vitamin E, a substance that normally protects red blood cells against oxidation.
Excessive blood drawing for electrolytes, complete blood counts, or blood gas analysis
after birth can potentiate the problem. For this reason, it’s important to see that blood
draws in preterm infants are coordinated to the fewest possible and a record of the blood
loss for these tallied. Delaying 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 (Frank,
Mueller-Burke, Bullard, et al., 2015).

Acute Bilirubin Encephalopathy

Acute bilirubin encephalopathy (ABE) is the destruction of brain cells by invasion of
indirect or unconjugated bilirubin (Mesić, Milas, Medimurec, et al., 2014). This
invasion results from the high concentration of indirect bilirubin that forms in the
bloodstream from an excessive breakdown of red blood cells at birth. Preterm infants
are more prone to this condition than term infants because, with the acidosis that occurs
from poor respiratory exchange, brain cells appear 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. Because of this, ABE may occur at
lower levels in these infants than in term newborns (Thilo & Rosenberg, 2012). At the
point that indirect bilirubin levels rise and jaundice occurs, phototherapy or exchange
transfusion can be initiated to prevent excessively high indirect bilirubin levels.

Persistent Patent Ductus Arteriosus

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Because preterm infants may 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 then interferes with closure of
the ductus arteriosus. Always administer intravenous therapy cautiously to preterm
infants, therefore, because increasing blood pressure could further compound this
problem. In term infants, indomethacin or ibuprofen may be used to cause closure of a
patent ductus arteriosus, making ventilation more efficient; however, indomethacin is
given cautiously to preterm infants because it has been associated with adverse effects
such as decreased renal function, decreased platelet count, and gastric irritation (Mitra,
Florez, Tamayo, et al., 2014). Carefully monitor urine output and observe for bleeding,
especially at injection sites, if this is prescribed.

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 of fragile capillaries and immature cerebral vascular development. When there
is a rapid change in cerebral blood pressure, such as could occur with hypoxia,
intravenous infusion, ventilation, or pneumothorax (lung collapse), capillary rupture
could occur; brain anoxia then occurs distal to the rupture.
Intraventricular hemorrhage occurs most often in VLBW infants and is classified as:
• Grade 1, bleeding in the periventricular germinal 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 the ventricles
• Grade 4, bleeding in the ventricles and intraparenchymal hemorrhage
A long-term effect of hemorrhage may be the development of hydrocephalus if there
was bleeding into the narrow aqueduct of Sylvius (Robinson, 2012). Preterm infants
usually have a cranial ultrasound performed after the first few days of life and again at
different intervals based on the gestational age of the infant to detect if a hemorrhage
has occurred. Infants with grade 1 or 2 bleeds have a good long-term prognosis; the
prognosis of those with more intense bleeds is guarded until further complications are
ruled out (Shah & Wusthoff, 2016).

Other Potential Complications

Preterm infants are also particularly susceptible to several illnesses in the early postnatal
period, which can also occur in term infants, including respiratory distress syndrome,
apnea, and retinopathy of prematurity (all discussed later in this chapter), as well as
necrotizing enterocolitis (discussed in Chapter 45).

Nursing Diagnoses and Related Interventions

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Because a preterm infant has few body resources, both physiologic and psychological
stress must be reduced as much as possible and interventions should be initiated
gently to prevent the depletion of available resources. Close observation and an
analysis of findings are essential so concerns can be managed quickly.
Nursing Diagnosis Risk: Impaired gas exchange related to immature pulmonary
functioning
Outcome Evaluation: Newborn initiates breathing at birth after resuscitation;
maintains normal newborn respirations of 30 to 60 breaths/min free of assisted
ventilation; exhibits oxygen saturation levels of at least 95% as evidenced by pulse
oximetry.
Preterm infants have great difficulty initiating respirations at birth because pulmonary
capillaries are still so immature, and lung surfactant, which does not form in adequate
amounts until about the 34th to 35th week of pregnancy, may not be present.
Inadequate lung surfactant leads to alveolar collapse with each expiration. This
collapse forces the infant to use maximum strength to inflate lung alveoli each time.
Because this is so tiring, it becomes very difficult for infants to maintain effective
ventilations under these stressful conditions.
Cesarean birth, although it has the advantage of reducing pressure on the
immature head, may be elected with a preterm birth but also may lead to additional
respiratory complications because infants born by cesarean birth retain more lung
fluid than those born by vaginal birth. Giving the mother oxygen by mask during the
birth can help provide a preterm infant with optimal oxygen saturation at birth (85%
to 90%). Keeping maternal analgesia and anesthesia to a minimum also offers a
preterm infant the best chance of initiating effective respirations.
Even term infants experience temporary respiratory acidosis until they take a first
breath. Once respirations are established, however, this condition quickly clears.
Because preterm infants cannot initiate effective respirations as quickly as mature
infants, they are susceptible to irreversible acidosis. Birthing room teams need to be
prepared with preterm-size laryngoscopes, endotracheal tubes, suction catheters, and
synthetic surfactant to be administered by the endotracheal tube so resuscitation can
be accomplished immediately. Be certain infants are kept warm during resuscitation
so they do not have to expend extra energy to increase metabolic rate to maintain
body temperature. Be certain as well that all procedures are carried out gently; a
preterm infant’s tissues are extremely sensitive to trauma and can be damaged or
bruised easily by an oxygen mask. When blood from bruising is reabsorbed, this
could yet lead to hyperbilirubinemia (an excess amount of bilirubin in the blood).
Many preterm babies, particularly those under 32 weeks of age, continue to have
an irregular respiratory pattern (a few quick breaths, a period of 5 to 10 seconds
without respiratory effort, a few quick breaths again, etc.). 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. If true

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apnea, which needs immediate attention, is occurring, the pause in respirations is
more than 20 seconds and usually results in bradycardia.
The soft rib cartilage of a preterm infant is yet another source of respiratory
problems because it causes ribs to collapse on expiration. The accessory muscles of
respiration may be underdeveloped as well, leaving preterm infants with no backup
muscles to use when they become fatigued. Because of this, preterm infants may need
continued oxygen administration after resuscitation to allow them to effectively
maintain respirations.
Giving a high level of oxygen to preterm infants during resuscitation or to
maintain respirations presents two additional dangers: pulmonary edema and ROP.
The development of both of these conditions depends on saturation of the blood with
oxygen (Po2) of more than 100 mmHg, which usually occurs when oxygen is
administered at a concentration over 70% (Abdel Ghany, Alsharany, Ali, et al.,
2016).
Nursing Diagnosis: Risk for deficient fluid volume related to insensible water loss at
birth and small stomach capacity
Outcome Evaluation: Plasma glucose is between 40 and 60 mg per 100 ml; specific
gravity of urine is maintained at 1.003 to 1.020; urine output is maintained at a
minimum of 1 ml/kg/hr; electrolyte levels are within normal limits.
A preterm newborn experiences a high insensible water loss because of a large body
surface relative to total body weight. Preterm infants also cannot concentrate urine
well because of immature kidney function. Because of this, a high proportion of body
fluid is excreted. All these factors may make a preterm baby need a higher percentage
of fluid daily than a term infant (Mohan & Jain, 2012).
Intravenous fluid should be given via a continuous infusion pump to ensure a
constant infusion rate and to prevent accidental overload. Assess intravenous sites
conscientiously because, if infiltration should occur, the lack of subcutaneous tissue
places a preterm newborn at risk for damaged tissue. Specially designed small gauge
needles are available for use on small veins. However, many preterm infants lack
adequately sized peripheral veins for even this small of a needle. Therefore, they need
to receive intravenous fluid by an umbilical or central venous catheter.
Monitor the baby’s weight, urine output and specific gravity, and serum
electrolytes to ensure adequate fluid intake because too little fluid and calories can
lead to weight loss, dehydration and starvation, and increased acidosis. Overhydration
may lead to nonnutritional weight gain, pulmonary edema, and heart failure.
Most preterm infants void and pass meconium within 24 hours after birth,
although this is delayed in very small infants. Measure urine output by weighing
diapers rather than using urine collection bags because disposable collection bags can
lead to skin irritation and breakdown from frequent changing and leaking.
The amount of urine output for the first few days of life in preterm babies is high
in comparison with that of the term baby because of poor urine concentration: 40 to

1501
100 ml/kg per 24 hours, compared with 10 to 20 ml/kg per 24 hours, respectively.
The specific gravity is low, rarely more than 1.012 (normal term babies may
concentrate urine up to 1.030). Test urine as well for glucose and ketones because
these can reveal hyperglycemia caused by the glucose infusion, which then can lead
to diuresis and extreme fluid loss. If too little glucose is being supplied and body cells
are using protein for metabolism, ketone bodies will appear in the urine.
Blood glucose determinations should range between 40 and 60 mg/dl. Check for
blood in stools to evaluate possible bleeding from the intestinal tract because this can
help determine a cause of hypovolemia if this occurs.
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements,
related to additional nutrients needed for maintenance of rapid growth, possible
sucking difficulty, and small stomach
Outcome Evaluation: Infant’s weight follows percentile growth curve, skin turgor is
good, specific gravity of urine is maintained between 1.003 and 1.020; the infant has
no more than 15% weight loss in the first 3 days of life and continues to gain weight
after this point.
Nutrition problems can arise with a preterm infant because the infant’s body is
attempting to continue to maintain the rapid rate of intrauterine growth appropriate
for the gestational age. Because of this, a preterm newborn requires a relatively larger
amount of nutrients than the mature infant, 115 to 140 calories per kilogram of body
weight per day compared with 100 to 110 calories per kilogram of body weight per
day needed by a term infant. Protein requirements are 3 to 3.5 g per kilogram of body
weight, compared with 2.0 to 2.5 g per kilogram for a term newborn. Because
preterm infants have a smaller stomach capacity than term neonates, as a rule, they
must be fed more frequently with smaller amounts than term infants, perhaps as small
as 1 or 2 ml every 2 to 3 hours.
If these nutrients are not supplied, an infant can develop hypocalcemia (decreased
serum calcium) or azotemia (low protein level in the blood). Delayed feeding and a
resultant decrease in intestinal motility may also add to hyperbilirubinemia, a
problem infants already are at high risk of developing when fetal red blood cells
begin to be destroyed.
Digestion and absorption of nutrients in a preterm infant’s stomach and intestine
may be immature, making the digestion of milk difficult. Nutrition problems are
further compounded by a preterm infant’s immature reflexes, which make
swallowing and sucking difficult. Increased activity that occurs from ineffective
sucking may increase the metabolic rate and oxygen requirements; if this happens, it
increases the caloric requirements even more. In addition, the preterm infant’s
stomach capacity is so small that feedings quickly fill the stomach. If a small stomach
is distended from a full feeding, this puts pressure on the diaphragm and can lead to
respiratory distress. An immature cardiac sphincter (between the stomach and
esophagus) allows regurgitation to occur readily. The lack of a cough reflex may lead

1502
an infant to aspirate regurgitated formula.
Feeding Schedule. With the early administration of intravenous fluid to prevent
hypoglycemia and supply fluid, feedings may be safely delayed until an infant has
stabilized his or her respiratory effort from birth. Very preterm infants may be fed by
total parenteral nutrition until they are stable enough for enteral feedings. Breast,
gavage, or bottle feedings are then begun as soon as the infant is able to tolerate them
to prevent the deterioration of the intestinal villi. Preterm infants may have a chest X-
ray taken before a first feeding. The presence of air in the stomach shows that the
route to the stomach is clear or that no anomaly such as a tracheoesophageal fistula
exists.
Gavage Feeding. Although a sucking reflex is present earlier, the ability to coordinate
sucking and swallowing is inconsistent until approximately 34 weeks of gestation. A
gag reflex is not intact until 32 weeks of gestation. For this reason, for infants who
are ill or experiencing respiratory distress may be started on gavage feedings; bottle
feeding or breastfeeding will then be gradually introduced as the infant matures and
begins to demonstrate feeding behaviors such as being awake, moving, or fussing as
if hungry (Fig. 26.8). To avoid tiring, preterm nipples with a slightly larger hole than
regular nipples and that are softer are used for bottle feedings.

Figure 26.8 Feeding a preterm infant. Notice the small bottle used.
(Fuse/PunchStock.)

Observe preterm infants closely after oral or gavage feeding to be certain their
filled stomach is not causing respiratory distress. Offering a pacifier during gavage
feeding can help strengthen the sucking reflex, better prepare an infant for bottle
feeding or breastfeeding, and provide oral satisfaction.
Gavage feedings may be given intermittently every few hours or continuously via
tubes passed into the stomach or intestine through the mouth or nose. This can be
helpful for infants on ventilators or those who cannot tolerate intermittent feedings

1503
because of the volume. If feedings are given intermittently, stomach contents may be
aspirated, measured, and replaced before each feeding. An infant who has a large
amount of milk left in the stomach (volume depends on the amount of milk the infant
is receiving) is not digesting the milk. Feedings should not be increased and possibly
even cut back to ensure better digestion and to decrease the possibility of
regurgitation and aspiration. An inability to digest in this way is also a sign that
necrotizing enterocolitis, a destructive intestinal disorder that often occurs in preterm
babies, may be developing (Su, Lin, Huang, et al., 2015) (see Chapter 45).
Breast Milk. There is increasing evidence that although preterm infants grow well on
commercial formulas, the best milk for them, the same as with term infants, is breast
milk (Briere, McGrath, Cong, et al., 2016). The immunologic properties of breast
milk may play a major role in preventing neonatal necrotizing enterocolitis as well as
an increase in immune defenses.
Mothers can express breast milk manually or with a breast pump for their infant’s
gavage feedings. If a woman cannot bring this in daily, she can freeze it for safe
transport and storage. The sodium content of breast milk in a mother whose infant
was born preterm is higher than that of milk in a mother whose infant has been born
at term. Therefore, it is better for infants to receive their own mother’s breast milk
rather than banked milk if possible. This high level of sodium seems to be necessary
for fluid retention in the preterm infant. Breast milk is 20 calories per ounce, so
parents may be advised to add a human milk fortifier to supplemental bottles of
breast milk to supply additional calories, protein, vitamins, and minerals (Brooks,
Vickers, & Aryal, 2013). Urge mothers to continue to breastfeed their preterm infants
after hospital discharge.
Formula. The caloric concentration of formulas used for preterm infants is usually 22
calories per ounce compared to 20 calories per ounce for a term baby (Mohan & Jain,
2012). Supplementing additional minerals such as iron, calcium, and phosphorus and
electrolytes such as sodium, potassium, and chloride may be necessary, depending on
the newborn’s blood studies. Vitamin A is important in improving healing and
possibly reducing the incidence of lung disease. Vitamin E seems to be important in
preventing hemolytic anemia in preterm infants (Londhe, Nolen, Das, et al., 2013).
Nursing Diagnosis: Ineffective thermoregulation related to immaturity
Outcome Evaluation: Infant’s temperature is maintained at 97.6°F (36.5°C) axillary.
Preterm newborns have a great deal of difficulty maintaining body temperature
because they have a relatively large surface area per kilogram of body weight. In
addition, because they do not flex their body well but remain in an extended position,
rapid cooling from evaporation is more likely to occur.
A preterm infant has little subcutaneous fat for insulation and poor muscular
development and so cannot move as actively as an older infant to produce body heat.
A preterm infant also has a limited amount of brown fat, the special tissue present in

1504
newborns that helps maintain body temperature. Preterm infants also cannot shiver, a
useful mechanism to increase body temperature, nor can they sweat and thereby
reduce body temperature because of their immature central nervous system and
hypothalamic control. This makes preterm infants dependent on the environmental
temperature provided to keep warm. In a birthing room, typically kept at 62° to 68°F
(16.6° to 20°C), a 1,500-g infant exposed to this low temperature loses 1°C of body
heat every 3 minutes if left unprotected. Keeping preterm infants under radiant heat
warmers, in incubators, or warmed by skin-to-skin contact helps to counteract this
natural cooling. It is recommended that the birthing room temperature be increased to
76°F. Be certain a radiant heat warmer is prewarmed before the infant is born. Unless
there are obvious abnormalities noted, a physical assessment of a preterm infant, even
weighing, can be delayed until the infant can be placed in the warmth of an incubator
or under a radiant warmer with a servo control. Some radiant warmers are equipped
with built-in scales to weigh the newborn.
If an infant is going to be transported to a department within the hospital, such as
the X-ray department, or to a regional center for specialized care, keeping the
newborn warm during transport is crucial. Remember that infants lose heat by
radiation as well as conduction. If a warmed incubator is placed in a cold transport
ambulance, for example, the infant will lose heat to the distant source. An additional
heat shield or plastic wrap may need to be placed over an infant, or a portable
warming mattress can be placed under the infant to help conserve heat during
transport.
Nursing Diagnosis: Risk for infection related to immature immune defenses in the
preterm infant
Outcome Evaluation: Temperature is maintained at 97.6°F (36.5°C) axillary; further
signs and symptoms of infection such as poor growth or a reduced temperature are
absent.
The skin of a preterm infant is easily traumatized and therefore offers less resistance
to infection than the skin and mucous membrane of a mature infant. In addition,
preterm infants have a lowered resistance to infection because they have difficulty
producing phagocytes to localize infection as well as a deficiency of immune globulin
M (IgM) antibodies because of insufficient production. To help prevent infection,
linen and equipment used with preterm infants must not be shared with other infants.
Staff members must be free of infection, and hand washing and gowning (if
indicated) regulations should be strictly enforced.
Nursing Diagnosis: Risk for impaired parenting related to interference with parent–
infant attachment resulting from hospitalization of infant at birth
Outcome Evaluation: Parents visit frequently and hold the infant; parents speak of
their child in positive terms.
In a preterm infant, the first and second periods of reactivity normally observed in

1505
newborns at 1 hour and 4 hours of life (see Chapter 18) may be delayed. In some
infants, no period of increased activity or tachycardia may appear until 12 to 18 hours
of age. If the purpose of a period of reactivity is to stimulate respiratory function, this
places a preterm infant at an even greater threat of respiratory failure because
respiratory efforts may not be stimulated. A second consequence of a delayed period
of reactivity is the loss of an opportunity for interaction between parents and the
newborn in the early postpartum period.
Although it is extremely important to conserve a preterm infant’s strength by
reducing sensory stimulation as much as possible and handling an infant gently,
preterm infants appear to need as much attention and affection as term newborns.
Rocking, singing and talking to them, and gentle holding them are measures to help
preterm infants develop a sense of trust in people, which will enable them to relate
satisfactorily to people in the future. Encourage parents to begin interacting with their
infant as soon as possible (Box 26.4). Holding an infant with skin-to-skin contact is
an effective way to begin this interaction.

BOX 26.4
Nursing Care Planning to Empower a Family
Guidelines for Parents of a Newborn in Intensive Care
Q. Mrs. Atkins tells you, “I’m always afraid I’ll touch the wrong thing when I visit
our son in the neonatal intensive care unit. What can I do to feel more comfortable
there?”
A. Here are some guidelines that should be helpful:
• Learn the name of your child’s primary healthcare provider and primary nurse or
care manager. Make a point of talking to them when you visit so the information
you receive is consistent and so these important people can get to know you.
• Discuss with your child’s primary nurse the time you will usually visit so she or he
can schedule your baby’s procedures and rest times other than when you visit so
there is time for you to hold your child and interact with him uninterrupted.
• Ask for explanations of any equipment or medications being used with your child
so you understand the plan of care. Insist on being included in care decisions. The
nurses are always nearby and will be happy to explain what can be touched and
moved and what should be left alone for now.
• Any day you are unable to visit, call the nursery and ask to talk to your child’s
primary care nurse. Such telephone calls are not viewed as a bother but are
welcomed as the mark of a concerned parent.
• Ask if you can supply expressed breast milk for your infant as soon as feedings are
started so you can feel you’re having a greater part in your baby’s care.
• You might supply a tape recording of your voice so your baby can learn to
recognize it, as well as supply a small toy for your baby’s bed. These actions not

1506
 only supply auditory and visual stimulation for your infant but also help to give
you a more “normal” feeling toward infant care.
• Use your baby’s name when you talk about him (not “the baby”) to help you gain
a firm feeling that this is your baby, not the nursery’s.
• If your child is hospitalized a distance from home, ask if transfer to a local hospital
in a less technical environment will be possible as soon as he’s not so ill.

Before effective bonding can be established, parents may need time to come to
terms with their feelings of disappointment that the infant is so small or guilt that they
were not able to prevent the preterm birth. Helping them air these feelings and
develop a more positive attitude toward their preterm infant is an important nursing
responsibility.
Because parents may not be psychologically ready for birth when a preterm infant
is born, it may be more difficult for them to believe they have a child and to begin
interacting than if the infant had been born at term. Even if an infant cannot be
removed from an incubator or a radiant heat warmer, parents can still handle and
stroke the infant in the incubator or warmer for interaction. Encourage the mother to
come to the nursery and hold the infant before and after gavage feedings and to
breastfeed or bottle feed as soon as the baby is ready for this. By feeding her infant or
expressing milk for feedings, the mother is directly participating in care and learning
the first steps of her new role.
If the baby is going to be transferred to a regional center, make sure the parents
have an opportunity to see the infant before the transfer. A photograph of the infant
for them to keep is helpful in making the birth more real. Encourage them to visit the
distant site as often as possible. Sending them photos snapped with a cell phone or
pasting notes as if they’re messages from the baby taped to the incubator or warmer
(“Hi, Mom & Dad. I’m doing well”) for them to see when they visit can not only
keep parents involved but also help with bonding.
On days they cannot visit, parents can still stay in touch by telephone, video, or
nursery e-mail. By these means, by the time the baby is ready for discharge, the
parents should be able to feel they are taking home “their” baby, one whom they
know and have already begun to love.
Parents visiting a high-risk nursery often need a great deal of support from
nursing personnel. Remember that, although radiant warmers, incubators, ventilators,
and monitors are familiar equipment to nurses, they are unusual and frightening to
parents (Box 26.5). In such a high-tech setting, a parent may want very much to touch
his or her infant but is so afraid touching might set off an alarm that he or she stands
with arms folded (Fig. 26.9).

BOX 26.5
Nursing Care Planning Tip for Effective Communication

1507
Mrs. Atkins gave birth 2 days ago to a 2-lb boy at 30 weeks of pregnancy who has
been classified as a small-for-gestational-age preterm infant. Although you have told
Mrs. Atkins twice she is welcome to visit the neonatal intensive care unit (NICU) as
much as she’d like, you notice her electronic record indicates she has done so only
once.
Tip: Ask enough questions to determine what the patient wants without making
assumptions. In this scenario, the nurse could have assumed waiting for the husband
to come to the hospital was what was important, but the patient most desired another
person to accompany her to the nursery—a need the nurse could meet. Visiting a
NICU can be intimidating for parents, not only because of the high-tech equipment
that surrounds their baby but also because their baby often appears much smaller or
sicker than they imagined.
Nurse: Mrs. Atkins, I’ve noticed you haven’t been to the nursery to see your son yet.
Mrs. Atkins: I’m waiting for my husband to get here.
Nurse: Will that be today?
Mrs. Atkins: Tomorrow. He’s still out of town on business.
Nurse: Have you called the nursery and asked about your son?
Mrs. Atkins: I’m waiting for my husband. We’ll do it together.
Nurse: I know it seems important for you to go as a family, but I hate to see you miss
these first few days with your son. What if I go with you?
Mrs. Atkins: Could you? I absolutely can’t go up there alone.

Figure 26.9 Encourage families to visit with immature infants to

establish bonding. (Phanie/Alamy Stock Photo)

Because preterm infants can be hospitalized for long periods, parents can feel
baffled by receiving information from a parade of different healthcare providers or a
different person every time they visit. Primary nursing or case management with one
nurse as the consistent caregiver helps to reduce the number of people who contact

1508
the parents and who communicate the parents’ needs to the rest of the staff.
Try to make a baby’s siblings as welcome in a high-risk nursery as the baby’s
parents in order to build family unity. Check to be certain siblings do not have an
upper respiratory infection or fever. Also, their immunizations should be up to date
and they should not have been recently exposed to a communicable disease, such as
chickenpox, before they visit.
Nursing Diagnosis: Deficient diversional activity (lack of stimulation) related to
preterm infant’s rest needs
Outcome Evaluation: Infant demonstrates interaction with caregivers by attuning to
faces or voices. Preterm infants need rest to conserve energy for growth and
respiratory function, to combat hypoglycemia and infection, to stabilize temperature,
and to develop inner balance and attentiveness. To allow for this, try to organize
procedures to maximize the amount of rest available to an infant. If not a coordinated
effort, an infant may be awakened constantly for procedures. Preterm infants may
have more difficulty blocking out stimuli than term infants do because their nervous
systems are so immature. They may demonstrate they are overstimulated by such
behaviors as gagging, crying, splaying fingers and toes, or going limp when exposed
to bright lights, noise, pain, or overly strenuous handling. Because these infants have
little strength to move away from an unwanted stimulus, it is a caregiver’s
responsibility to be sensitive to these cues and move the object or noise away from
the infant (Silberstein & Litmanovitz, 2016). Until ready to take in stimuli, the infant
may need to be shielded from noise and light and pain may need to be limited as
much as possible.
Just as a preterm infant needs rest, he or she also needs planned periods of
pleasing sensory stimulation. Like all newborns, preterm infants respond best to
stimulation that appeals to their senses of sight, sound, and touch. A passive face,
picture, or decal may be appealing for only a short period of time.
The acrylic dome of an incubator can distort an infant’s view. Also, most people
view an infant in an incubator with themselves standing up and the infant lying
horizontally. This means that an infant’s face is rarely in the same line of vision as
the adult’s (an en face position). It is important to look directly at an infant in the
straightforward position as much as possible so the infant is provided with the
stimulation of a human face. As infants mature, they should have mobiles (perhaps
black and white) or bright objects placed in view. As an infant’s position is changed
from the left side to the right side, move the object to be in line with the child’s
vision.
Infants in closed incubators may be able to hear nothing but the sound of the
incubator motor. They may see people looking or nodding at them and may see their
mouths moving, but they cannot benefit from the sound of their voices because this is
obscured by the continuous hum of the motor. To help them hear better, provide
some “talk time”—words spoken softly but clearly into an infant’s ear during each

1509
nursing shift, perhaps while the infant is being fed out of the incubator, to offer usual
sensory stimulation.
Even an infant who cannot be removed from an incubator should not suffer from
lack of touch. Gently stroking an infant’s back or smoothing the back of the head
should not be tiring. Pulse oximetry can be used to help you recognize when an infant
is comforted by handling (e.g., oxygen saturation remains steady or increases) and
when the infant is growing tired (e.g., oxygen saturation falls). Be certain during
every nursing shift that close interaction is provided, particularly if clinical
interventions with an infant include uncomfortable procedures such as suctioning or
blood drawing. As soon as infants can be out of incubators or removed from
warmers, they need special time just to be rocked and held.
Nursing Diagnosis: Risk for disorganized infant behavior related to prematurity and
environmental overstimulation
Outcome Evaluation: Newborn’s vital signs remain within normal limits; infant
demonstrates increasing ability to adapt to stimuli; demonstrates decreasing levels of
irritability, crying, respiratory pauses, tachypnea, and color changes.
The amount of rest and stimulation required by preterm infants for healthy
development is best individualized. Developmental care (care designed to meet the
specific needs of each infant) can lead to increased weight gain and decreased crying
and apnea spells in preterm infants (Samra, McGrath, Wehbe, et al., 2012) (Box
26.6).

BOX 26.6
Developmental Care

Developmental care is care individually designed based on a preterm infant’s

behavioral cues to meet the special needs of a preterm or newborn infant. Common
measures include:
PARENT WELCOMING PROCEDURES
• Make parents feel welcome in a neonatal intensive care environment by both
words and actions.
• Provide room around incubators or warmers for rocking chairs so parents can hold
their baby comfortably.
• Encourage parent participation in feeding or supplying nonnutritive sucking
experiences.
• Demonstrate the infant’s capabilities and how, although immature, these are
correct for the infant’s age or weight.
• Keep parents informed of their baby’s progress and the rationale for therapies.
• Ask parents for input into their baby’s rhythm of care that will best suit them and
the infant after they return home.

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INFANT DEVELOPMENTAL PROCEDURES
• Provide a consistent routine to help the infant develop sleep/wake cycles.
• Time infant care and feeding based on the sleep/wake cycle of the infant.
• Cluster aspects of care so the infant enjoys the longest possible sleep intervals to
conserve energy.
• Provide a “nest” with blankets to offer a sense of boundaries or security.
• Position infants so they can self-soothe—curled on side, or hands near face, knees
tucked near body, or whatever way each baby seems to prefer.
• Provide quiet or rest times by covering an incubator and limiting sound.
• Provide tactile stimulation by back stroking or massage.
• Provide audio and visual stimulation by the use of mobiles and music or a parent’s
voice.
• Halt procedures as soon as the infant evidences stress.

Because preterm infants have an immature central nervous system, their reactions
or adjustments to stimuli may be different from those of term infants. The
environment of an intensive care unit is also totally different from what infants would
have experienced if they had remained in utero until term. Based on these two
premises, nursing care should be geared toward making the environment of infants as
atraumatic as possible while helping them adjust to new experiences within their
limited ability.
The usual sound level of nurseries, for example, has been documented to be about
40 to 50 dB; a radio playing raises this to 60 to 65 dB. The closing of portholes or
tapping on the sides of incubators raises the sound level inside them to 80 dB or
more, or a sound level that can be painful. Other abnormal stimuli are bright lights for
24 hours a day, frequent handling, and painful procedures.
Activities such as dimming the lights or covering an incubator, turning an infant
to the side and containing the body with rolled towels (nesting), offering nonnutritive
sucking, and maintaining a “quiet hour” to reduce sound are all ways to reduce
stimuli or construct an environment conducive to healthy development (Laubach,
Wilhelm, & Carter, 2014).
Nursing Diagnosis: Parental health-seeking behaviors related to preterm infant’s
needs for health maintenance
Outcome Evaluation: Parents describe schedule for basic immunizations and health
assessments and state who will provide ongoing health care.
Discharge from a NICU is a major transition for parents as well as their infant. Before
discharge, the parents of a preterm infant need to learn and practice any special
methods of care necessary for their infant and interventions to help maximize their
child’s development. Some parents tend to overprotect preterm infants, such as not
allowing visitors or not taking an infant outside. Let parents know their concern is

1511
 normal, but overprotection is not necessary.
Ongoing health maintenance of a preterm infant follows the usual pattern of well-
child care. Basic immunizations are given according to the chronologic age of an
infant. In many communities, NICUs maintain their own well-child settings for
infants who were hospitalized there. This allows for long-term follow-up studies on
the effect of oxygen or drug therapy and continuity of care. Many parents prefer
bringing their infant back to such a facility rather than establishing a new network of
health care because they have already established trust and confidence in that
healthcare team. This often also increases their self-esteem because they hear the
staff’s delight in the progress made by their child. However, preterm infants can be
followed by any healthcare provider for well-child care.
When plotting the height and weight of preterm infants at well-child visits,
remember to account for early birth on the growth chart by double charting—that is,
plotting the child’s weight and height according to the chronologic age (a pattern that,
in the early months, probably places the child below the 10th percentile). Then, in
another color, plot the height and weight according to an infant’s adjusted age, or plot
the weight of a baby born 2 months early 2 months earlier on the graph. A preterm
baby typically gains “catch-up” weight in the first 6 months of life, so by 1 year of
age, a baby plots over the 10th percentile on a growth chart without accounting for a
setback age.
Evaluate growth and developmental milestones of a preterm infant in the same
manner. A preterm infant can be expected to meet first-year milestones not at the
chronologic age but at the setback age. To evaluate the parents’ transition to having
so small an infant at home, ask at health promotion visits if the parents are:
• Beginning to feel more comfortable with their infant
• Able to allow the child to stay with a babysitter or another family member
• Beginning to incorporate their infant into their family life
• Making plans for the infant beyond the immediate newborn period

QSEN Checkpoint Question 26.2

Teamwork & Collaboration
Baby Atkin’s father plays in a garage band for a hobby, and his mother enjoys
knitting. The nurse’s care team has agreed to design a developmental care
environment for Baby Atkins that will both make him feel secure and help his parents
interact more with him. The care team determines which action is best?
a. Turning up the lights in his part of the nursery so he can see his parents better
b. Asking the father to bring in a recording of his band to play for the baby
c. Arranging a blanket Mrs. Atkins has knit into a circle or “nest” for the baby
d. Reminding the parents that he must stay awake for extended periods for his
eyes to fully develop

1512
 Look in Appendix A for the best answer and rationale.

THE SMALL-FOR-GESTATIONAL-AGE INFANT

An infant is SGA (also called microsomia) if the birth weight is below the 10th
percentile on an intrauterine growth curve for that age. Such infants may be born:
• Preterm: before week 38 of gestation
• Term: between weeks 38 and 42
• Postterm: past 42 weeks
SGA infants are small for their age because they have experienced intrauterine
growth restriction (IUGR) or failed to grow at the expected rate in utero (Rahimian,
2013). This characteristic makes them distinctly different from infants who are born
with a less weight than usual but their low weight is consistent for their gestational age.

Etiology
A woman’s nutrition during pregnancy plays a major role in fetal growth, so a lack of
adequate nutrition may be a major contributor to IUGR (Ota, Tobe-Gai, Mori, et al.,
2012).
Adolescents are prone to having a high incidence of SGA infants because if they eat
only enough to meet their own nutritional and growth needs, the needs of a growing
fetus can be compromised. In still other instances, the placental supply of nutrients is
adequate but an infant cannot use them because of a chromosomal abnormality or an
intrauterine infection such as rubella or toxoplasmosis.
Even in light of these nutritional influences, the most common cause of IUGR is a
placental issue: either the placenta did not obtain sufficient nutrients from the uterine
arteries or it was inefficient at transporting nutrients to the fetus. Placental
underdevelopment or damage, such as partial placental separation with bleeding is an
example of a situation that would limit placental function because the area of placenta
that separated infarcted and fibrosed, reducing the placental surface available for
nutrient exchange. Women with systemic diseases that decrease blood flow to the
placenta, such as severe diabetes mellitus or gestational hypertension (diseases in which
blood vessel lumens are narrowed), are at higher risk for birthing SGA babies than
others. Women who smoke heavily or use opiates also tend to have SGA infants
(Ortigosa, Friguls, Joya, et al., 2012).

Assessment
The SGA infant may be detected in utero when fundal height during pregnancy
becomes progressively less than expected. However, if a woman is unsure of the date of
her last menstrual period, this discrepancy can be hard to substantiate; a sonogram can
then demonstrate the decreased size. A biophysical profile including a nonstress test,
placental grading, amniotic fluid amount, and an ultrasound examination documents
additional information on placental function and fetal growth. If poor placental function

1513
is apparent from such determinations, it can be predicted that the infant will do poorly
during labor during the periods of relative hypoxia, which occur during contractions.
Cesarean birth, therefore, is the birth method of choice in such circumstances.

Appearance
Generally, an infant who suffers nutritional deprivation early in pregnancy, when fetal
growth consists primarily of an increase in the number of body cells, is below average
in weight, length, and head circumference. An infant who suffers deprivation late in
pregnancy, when growth consists primarily of an increase in cell size, may have only a
reduction in weight. Regardless of when deprivation occurs, the infant tends to have an
overall wasted appearance. The infant may have poor skin turgor and generally appears
to have a large head because the rest of the body is so small. Skull sutures may be
widely separated. Hair may be dull and lusterless. The infant may have a small liver,
which can cause difficulty regulating glucose, protein, and bilirubin levels after birth.
The abdomen may be sunken. The umbilical cord often appears dry and may be stained
yellow.
In contrast, because an infant’s age is more advanced than the weight implies, an
infant may have better developed neurologic responses, sole creases, and ear cartilage
than expected for a baby of that weight. The infant may also seem unusually alert and
active. As a first assessment, the SGA infant needs to be examined carefully for possible
congenital anomalies that occurred because of the poor nutritional intrauterine
environment.

Laboratory Findings
Blood studies at birth usually show a high hematocrit level (less than normal amounts of
plasma in proportion to red blood cells are present because of a lack of fluid) and an
increase in the total number of red blood cells (polycythemia). The increase in red blood
cells occurs because anoxia during intrauterine life stimulated excess development of
them. An immediate effect of polycythemia is to cause increased blood viscosity, a
condition that puts extra work on the infant’s heart because it is more difficult to
effectively circulate thick blood. As a consequence, acrocyanosis (blueness of the hands
and feet) may be prolonged and persistently more marked than usual. If the
polycythemia is extreme, vessels may actually become blocked and thrombus formation
can result. If the hematocrit level is more than 65% to 70%, an exchange transfusion to
dilute the blood may be necessary.
A second problem of polycythemia is hyperbilirubinemia because so many extra red
blood cells break down and release bilirubin.
Because SGA infants have decreased glycogen stores, still another common
problem that develops is hypoglycemia (decreased blood glucose, or a level below 45
mg/dl). Such infants may need intravenous glucose to sustain blood sugar until they are
able to suck vigorously enough to take sufficient oral feedings.

1514
 Nursing Diagnoses and Related Interventions

Nursing Diagnosis: Ineffective breathing pattern related to underdeveloped body

systems at birth
Outcome Evaluation: Newborn maintains respirations at a rate of 30 to 60
breaths/min after resuscitation at birth.
Birth asphyxia is a common problem for SGA infants, both because they have
underdeveloped chest muscles and because they are at risk for developing meconium
aspiration syndrome (MAS) as a result of meconium release, which occurs when fetal
anoxia develops during labor to cause reflex relaxation of the anal sphincter. When
gasping for breath in utero, the fetus draws meconium discharged from the intestine
into the amniotic fluid down into the trachea and bronchi. Acting as a foreign
substance, this blocks airflow into the alveoli and causes the SGA infant to need
resuscitation at birth. Closely observe both respiratory rate and character in the first
few hours of life as underdeveloped chest muscles not only make taking the first
breath difficult but can make SGA infants unable to sustain an adequate newborn
respiratory rate.
Nursing Diagnosis: Risk for ineffective thermoregulation related to lack of
subcutaneous fat
Outcome Evaluation: Infant’s temperature is maintained at 36.5°C (97.8°F) axillary.
SGA infants are less able to control body temperature than other newborns because
they lack subcutaneous fat. A carefully controlled environment is essential to keep
the infant’s body temperature in a neutral zone (see Chapter 18).
Nursing Diagnosis: Risk for impaired parenting related to child’s high-risk status
and possible cognitive or neurologic impairment from lack of nutrients in utero
Outcome Evaluation: Parents express interest in infant and ask questions about what
the child’s care needs will be at home; parents hold infant warmly.
Although SGA infants may gain weight and appear to thrive in the first few days of
life, their cognitive development may have been impaired because of lack of oxygen
and nourishment in utero. Babies who were growing normally in utero but whose
gestation was interrupted (true preterm, AGA babies) usually gain weight and height
so rapidly that by the end of the first year of life they are near the 50th percentile on
growth charts. SGA infants, in contrast, may always be below the usual height on
standard growth charts. This inability to reach normal levels of growth and
development can interfere with bonding if a child does not meet the parents’
expectations. Eventually, it can interfere with the child’s self-esteem if the child is
never able to meet parental expectations or reach full height.

1515
 Yet, another need of an SGA infant is adequate stimulation during the infant
period in order to reach normal growth and developmental milestones. Encourage
parents to provide toys suitable for their child’s chronologic age, not physical size.
Because an infant tires easily in the first few weeks of life, urge them to space play
periods with rest periods or hypoglycemia or apnea can occur. All infants with IUGR
need continued follow-up after hospital discharge because they may have neurologic
deficits that will interfere with learning at preschool age (Murray, Fernandes, Fazel,
et al., 2015).

THE LARGE-FOR-GESTATIONAL-AGE INFANT

An infant is LGA (also termed macrosomia) if the birth weight is above the 90th
percentile on an intrauterine growth chart for that gestational age. Such a baby appears
deceptively healthy at birth because of the weight, but a gestational age examination
often reveals immature development. It is important that LGA infants be identified
immediately so they can be given care appropriate to their gestational age rather than
being treated as term newborns (Sjaarda, Albert, Mumford, et al., 2014).

Etiology
Infants who are LGA have been subjected to an overproduction of nutrients and growth
hormone in utero. This happens most often to infants of women who are obese or who
have diabetes mellitus (Sjaarda et al., 2014). Multiparous women may also have large
babies because with each succeeding pregnancy, babies tend to grow larger. Beckwith–
Wiedemann syndrome, a rare condition characterized by general body overgrowth and
congenital anomalies such as omphalocele, may also be a cause.

Assessment
A fetus is suspected of being LGA when a woman’s uterus appears to be unusually
large for the date of pregnancy. Abdominal size can be deceptive, however. Because a
fetus lies in a flexed fetal position, he or she does not occupy significantly more space at
10 lb than at 7 lb. If a fetus does seem to be growing at an abnormally rapid rate, a
sonogram can confirm the suspicion. A nonstress test to assess the placenta’s ability to
sustain a large fetus during labor may be prescribed. Lung maturity may be assessed by
amniocentesis.
If an infant’s large size was not detected during pregnancy, it may be first
recognized during labor when the baby appears too large to descend through the pelvic
rim. If this happens, a cesarean birth may be necessary because shoulder dystocia (the
wide fetal shoulders cannot pass; or needs significant manipulation to pass through the
outlet of the pelvis) would halt vaginal birth at that point.

Appearance

1516
At birth, LGA infants may show immature reflexes and low scores on gestational age
examinations in relation to their size. They may have extensive bruising or a birth injury
such as a broken clavicle or Erb–Duchenne paralysis from trauma to the cervical nerves
if they were stressed in order for the wide shoulders to be born vaginally (see Chapter
51). Because the head is large, it may have been exposed to more than the usual amount
of pressure during birth, causing a prominent caput succedaneum, cephalohematoma, or
molding.
Because LGA newborn are large but often immature, they require the same cautious
care necessary for a preterm infant. Specific criteria for initial or continuing assessments
are shown in Table 26.2.

TABLE 26.2 Important Assessment Criteria for a Large-For-Gestational-Age

Infant
Assessment
Assess skin color for ecchymosis,
jaundice, and erythema
Assess motion of upper extremities is
spontaneous and also occurs in response
to a Moro reflex to detect if clavicle
fracture (crepitus or swelling may then
be palpated at the fracture site) or Erb’s
palsy caused by edema of the cervical
nerve plexus are present.
Assess asymmetry of the anterior chest or
unilateral lack of movement to detect
diaphragmatic paralysis from edema of
the phrenic nerve.
Assess eyes for evidence of unresponsive
or dilated pupils; assess for vomiting,
bulging fontanelles, or a high-pitched
cry suggestive of increased intracranial
pressure.
Assess for activities such as jitteriness,
lethargy, and uncoordinated eye
Rationale
Bruising occurs with vaginal birth
because of the large size; polycythemia
causes ruddiness of skin. Ecchymosis
is important to document because
jaundice may occur from breakdown of
ecchymotic collections of blood.
Clavicle or cervical nerve injuries may
occur because of problem at birth of
wider than usual shoulders.
The cervical nerve may be stretched by
birth of wide shoulders.
The larger than usual head can be more
compressed than usual resulting in
increased intracranial pressure.
Compression of the third, fourth, and
sixth cranial nerves limits eye
response; other signs are additional
signs of increased intracranial pressure.
Seizures are yet another indication of
increased intracranial pressure;

1517
 movements that suggest seizure activity. hypoglycemia seizures in newborns
from the result of a low glucose level
often produce the more vague
symptoms.

Cardiovascular Dysfunction
Polycythemia may occur in an LGA fetus as the fetus attempts to fully oxygenate more
than the average amount of body tissue. Following birth, observe LGA infants closely
for signs of hyperbilirubinemia that may result from absorption of blood from bruising
and breakdown of the extra red blood cells created by polycythemia. Assess the infant’s
heart rate also. If cyanosis is present, it may be a sign of poor heart function, but it could
also be from transposition of the great vessels, a serious heart anomaly associated with
macrosomia (see Chapter 41).

Hypoglycemia
LGA infants also need to be carefully assessed for hypoglycemia in the early hours of
life because large infants require large amounts of nutritional stores to sustain their
weight. If the mother had diabetes that was poorly controlled (the cause of the large
size), the infant would have had an increased blood glucose level in utero to match the
mother’s glucose level; this caused the infant to produce elevated levels of insulin. After
birth, these increased insulin levels will continue for up to 24 hours of life, possibly
causing rebound hypoglycemia.

Nursing Diagnoses and Related Interventions

Nursing Diagnosis: Ineffective breathing pattern related to possible birth trauma in

the LGA newborn
Outcome Evaluation: Newborn initiates independent breathing at birth; maintains
usual newborn respiratory rate of 30 to 60 breaths/min.
Some LGA infants have difficulty establishing respirations at birth because of birth
trauma. Increased intracranial pressure from birth of the larger than usual head, for
example, could have led to pressure on the respiratory center causing a decrease in
respiratory function. If the infant was born vaginally, a diaphragmatic paralysis or
broken clavicle, both of which can prevent effective lung function, may have
occurred in order for the wide shoulders to be born. If the infant was born by cesarean
birth, transient fluid can remain in the lungs and can interfere with effective gas
exchange. Careful observation is needed, therefore, to detect all these conditions.
Care of an infant with transient lung fluid is discussed later in this chapter.

1518
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements,
related to additional nutrients needed to maintain weight and prevent hypoglycemia
Outcome Evaluation: Infant’s weight follows percentile growth curve, skin turgor is
good, specific gravity of urine is 1.003 to 1.020; serum glucose is above 45 mg/dl.
As a rule, an LGA infant needs to be fed immediately after birth (preferably by
breastfeeding) to prevent hypoglycemia. Evaluate carefully the intake of LGA infants
at this feeding so you don’t overestimate their ability to suck effectively. Such infants
may seem as if they should be able to suck well because they are already the size of a
2-month-old. However, despite their size, these infants are inexperienced newborns,
and sucking may not be effective enough to obtain the larger than usual amount of
milk needed.
These infants may need supplemental formula feedings after breastfeeding to supply
enough fluid and glucose for the larger than normal size for the first 24 hours.
Newborns who are offered bottles often have more difficulty than do others learning
to breastfeed, however, so in light of this, although it seems extreme, additional
glucose may be offered intravenously.
Nursing Diagnosis: Risk for impaired parenting related to high-risk status of LGA
infant
Outcome Evaluation: Parents hold infant warmly; speak of the child in positive
terms; state accurately why their infant needs to be closely observed in postnatal
period.
Parents may also underestimate this infant’s needs because of the child’s large size.
He or she seems so big and healthy, so it can be confusing to be told the infant needs
careful observation. If they are worried the infant must be sick in some way and they
are not being told about, it can interfere with bonding happening as instinctively as it
might. If a woman sustained a cervical or perineal tear or required a cesarean birth,
she may need some time to air any negative feelings she may be experiencing toward
the infant for causing her extra pain. Otherwise, her perception that her infant is the
cause of her additional distress is another factor that could interfere with her ability to
bond with the child.
Note whether parents treat their baby as a newborn who needs warm nurturing
care, not as a tough, big infant who has grown past that stage because the baby may
miss out on usual parental comforting measures. You may need to remind parents an
infant’s birth weight does not correlate with the child’s projected adult size.
Otherwise, parents may fear their infant may grow to be a larger than usual adult.

What If . . . 26.2
Mrs. Atkins tells the nurse she wishes her baby was 11 lb like the baby in the

1519
 incubator next to hers so he wouldn’t have any problems. What patient
education would the nurse provide?

THE POSTTERM INFANT

A postterm infant is one born after the 41st week of a pregnancy (Rahimian, 2013).
Infants who stay in utero past week 41 are 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 lose weight (postterm
syndrome). Infants with this syndrome demonstrate many of the characteristics of the
SGA infant: dry, cracked, almost leatherlike skin from lack of fluid, and an absence of
vernix. They may be SGA, and the amount of amniotic fluid surrounding them may be
less at birth than usual and it may be meconium stained. Fingernails will have grown
well beyond the end of the fingertips. Because they are older than a term infant, they
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 (see
Chapter 9) 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 is apt to occur during labor.
At birth, the postterm baby is likely to have difficulty establishing respirations,
especially if meconium aspiration occurred. Polycythemia may have developed from
decreased oxygenation in the final weeks. The hematocrit may be elevated because
polycythemia and dehydration have lowered the circulating plasma level. In the first
hours of life, hypoglycemia may develop because the fetus had to use stores of glycogen
for nourishment in the last weeks of intrauterine life. Subcutaneous fat levels may also
be low, having been used in utero. This loss of fat can make temperature regulation
difficult, making it important to prevent a postterm infant from becoming chilled at
birth or during transport.
Any woman is anxious when she does not have her baby on her due date. She is apt
to become extremely anxious and perhaps angry when it is determined her baby is
postterm. It seems that, if her baby stayed so long in utero under her protection, the
baby should be extra healthy and strong. Why, then, she asks, is her baby being
transferred for special care? The mother may also feel guilty for not providing well for
her infant in the last few weeks of the pregnancy.
Make certain 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 because 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 tasks.

1520
Illnesses That Occur in Newborns
A number of illnesses occur specifically in newborns that automatically cause the infant
to be classified as high risk.

RESPIRATORY DISTRESS SYNDROME

Respiratory distress syndrome (RDS) of the newborn, formerly termed hyaline
membrane disease, is most often seen in newborns born prematurely. Other causes of
RDS include newborns with meconium aspiration syndrome, sepsis, a newborn who is
slow to transition to extrauterine life, and pneumonia (Hermansen & Mahajan, 2015).
The pathologic feature of RDS is a hyalinelike (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 the exchange of oxygen and carbon dioxide at the
alveolar–capillary membrane, interfering with effective oxygenation. 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 LBW
infants and as many as 50% of VLBW premature infants are susceptible to this
complication.

Pathophysiology
High pressure is required to fill the lungs with air for the first time and overcome the
pressure of lung fluid. For example, it takes a pressure between 40 and 70 cm H2O to
inspire a first breath but only 15 to 20 cm H2O to maintain quiet, continued breathing. If
alveoli collapse with each expiration, as happens when surfactant is deficient, forceful
inspirations requiring optimum pressure are still required to inflate them.
Even very immature infants release a bolus of surfactant at birth into their lungs
from the stress of birth. However, with deficient surfactant, areas of hypoinflation begin
to occur and pulmonary resistance increases. Blood then shunts through the foramen
ovale and the ductus arteriosus as it did during fetal life. The lungs become poorly
perfused. As a result, the production of surfactant decreases even further.
The poor oxygen exchange that results leads to tissue hypoxia, which causes the
release of lactic acid. This, combined with the increasing carbon dioxide level resulting
from the formation of the hyaline membrane on the alveolar surface, leads to severe
acidosis. Acidosis causes vasoconstriction and decreased pulmonary perfusion from
vasoconstriction, which further limits surfactant production. With surfactant production
almost lost, the ability to stop alveoli from collapsing with each expiration becomes
more and more difficult. This vicious cycle continues until the oxygen–carbon dioxide
exchange in the alveoli is no longer adequate to sustain life without ventilator support.

Assessment

1521
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, such as:
• Low body temperature
• Nasal flaring
• Sternal and subcostal retractions
• Tachypnea (more than 60 breaths/min)
• Cyanotic mucous membranes
Within several hours, expiratory grunting occurs 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:
• Seesaw respirations (on inspiration, the anterior chest wall retracts and the
abdomen protrudes; on expiration, the sternum rises)
• Heart failure, evidenced by decreased urine output and edema of the extremities
• Pale gray skin
• Periods of apnea
• Bradycardia
• Pneumothorax
The diagnosis of RDS is made on the clinical signs of grunting, central cyanosis in
room air, tachypnea, nasal flaring, and retractions. A chest X-ray will reveal a diffuse
pattern of radiopaque areas that look like ground glass (haziness) in the lungs. Blood
gas studies will reveal respiratory acidosis. A β-hemolytic, group B streptococcal
infection may mimic RDS because this infection is so severe in newborns that it stops
surfactant production. Cultures of blood, cerebrospinal fluid, and skin may be obtained,
therefore, to rule out this condition. An antibiotic (penicillin or ampicillin) and an
aminoglycoside (gentamicin or kanamycin) may be started while culture reports are
pending.

Therapeutic Management

Surfactant Replacement
RDS can be largely prevented by the administration of surfactant at birth for an infant at
risk because of low gestational age (Box 26.7). Immediately after birth, synthetic
surfactant is administered into an endotracheal tube by a syringe or catheter (lung
lavage) (Wyckoff et al., 2015).

BOX 26.7

1522
Nursing Care Planning Based on Responsibility for Pharmacology

SURFACTANT (SURVANTA)
(http://survanta.com/dosage.cfm)
Action: Surfactant restores naturally occurring lung surfactant to improve lung
compliance.
Pregnancy Risk Category: X
Dosage: 4 ml/kg intratracheally; four doses in first 48 hours of life
Possible Adverse Effects: Transient bradycardia, rales
Nursing Implications
• 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 (Karch, 2013).

It’s important the infant is tipped to an upright position following administration and
the infant’s airway is not suctioned for as long as safely possible after administration of
surfactant to help it reach lower lung areas and to avoid suctioning the drug away.
Although there are almost no unfavorable reactions to surfactant administration, some,
such as mucus plugging from the solution, do occur. An infant who is receiving
surfactant and then is placed on a ventilator needs close observation because lung
expansion can improve so rapidly, the ventilator pressure becomes too high. Anticipate
the need to adjust ventilator settings to accommodate the vastly improved lung function.

Oxygen Administration
The administration of oxygen is often 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 exerts pressure on the alveoli at the end of expiration and helps keep
alveoli from collapsing in addition to supplying oxygen (Wyckoff et al., 2015). High-
frequency, oscillatory, and jet ventilation are still other methods of introducing oxygen
to infants with noncompliant lungs. These systems maintain airway pressure and then
intermittently “jet” or oscillate an additional amount of air at a rapid rate (400 to 600

1523
times per minute) to inflate alveoli.
A possible complication of oxygen therapy in the very immature or very ill infant is
ROP (see discussion later in chapter) or bronchopulmonary dysplasia (BPD) which is
also known as chronic lung disease (see Chapter 40).

Ventilation
Normally, on a ventilator, inspiration is shorter than expiration, or there is an
inspiratory/expiratory (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
(Kitsommart, Martins, Bottino, et al., 2012). 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 increased lung pressure. There is also a possible risk of increased intracranial and
arterial pressure and hemorrhage from fluctuating blood pressures. Being certain infants
are not overhydrated is important to help prevent increased blood pressure and increased
pulmonary artery pressure, which may delay the closure of the ductus arteriosus and
interfere with both heart and lung function.

Additional Therapy: Nitric Oxide

An additional therapy that can help to oxygenate a newborn’s lungs is the
administration of nitric oxide, a potent vascular dilator. It causes pulmonary
vasodilation without decreasing systemic vascular tone. It combines with hemoglobin in
the intravascular space to form methemoglobin. This causes systemic vasodilation. The
nitric oxide enters the alveoli on ventilation and redirects the pulmonary blood by
dilating the pulmonary arterioles (Nair & Lakshminrusimha, 2014).

Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) was first developed as a means of
oxygenating blood during cardiac surgery. Its current use has expanded to include the
management of severe hypoxemia in newborns with illnesses such as meconium
aspiration, RDS, pneumonia, and diaphragmatic hernia. Formerly used as a mainstay of
therapy for RDS, it is now rarely needed because surfactant lavage is so effective.

What If . . . 26.3
While the nurse was caring for Baby Atkins, who is ventilator dependent
and receiving the paralyzing agent pancuronium, a power failure occurred.
What would be the nurse’s first actions?

1524
Supportive Care
An infant with RDS must be kept warm because cooling increases acidosis in newborns,
and for the newborn with RDS, acidosis may increase to lethal levels. Keeping an infant
warm also reduces the infant’s metabolic oxygen demand. Provide hydration and
nutrition with intravenous fluids and glucose or gavage feedings because the respiratory
effort makes an infant too exhausted to suck. Box 26.8 shows an interprofessional care
map illustrating both nursing and team planning for a newborn with RDS.

BOX 26.8
Nursing Care Planning

AN INTERPROFESSIONAL CARE MAP FOR A NEWBORN WITH

RESPIRATORY DISTRESS SYNDROME
Mr. and Mrs. Atkins are the parents of a 30-week-old, 2-lb baby boy, born last night
after a short 4-hour labor.
Family Assessment: Family consists of two parents: Mr. Atkins works as a
consulting engineer; Mrs. Atkins worked before pregnancy as a home decorator. Mr.
Atkins was out of town on business so was not present for the infant’s birth. Mrs.
Atkins has not visited the intensive care nursery. She refused to sign the birth
certificate because she could not decide on a name. She said, “I don’t want to give
him our favorite name because he might die.” Mr. Atkins telephoned early this
morning and acted more upset the baby was born than relieved that the baby was
receiving intensive care. He asked his wife, “What did you do to cause this?”
Patient Assessment: A 2-lb newborn, 5 hours old, born vaginally. Had difficulty
establishing respirations at birth. Resuscitated by the neonatal nurse practitioner and
respiratory therapist and then transported to the intensive care nursery. Temperature:
97.2°F (36.2°C). Bradycardic and tachypneic with grunting respirations. Sternal and
subcostal retractions present. Skin pale and somewhat cyanotic. Chest X-ray shows
“ground-glass” appearance. Arterial blood gases (ABGs) reveal respiratory acidosis.
Endotracheal (ET) intubation, mechanical ventilation, supplemental oxygen, and
intravenous fluid therapy initiated.
Nursing Diagnosis: Impaired gas exchange related to immaturity of newborn’s lungs
and lack of surfactant
Outcome Criteria: Vital signs within acceptable parameters. Temperature
maintained at 97.7°F (36.5°C). Absence of cyanosis, diminished retractions, ABG
values within acceptable parameters, and no sound of grunting with respirations.

Team Member Expected

Responsible Assessment Intervention Rationale Outcome
Activities of Daily Living, Including Safety

1525
Nurse/neonatal primary Assess Maintain Signs of Infant
care provider team respiratory respiratory increasing maintains a
rate, depth, program as respiratory stable
and rhythm; prescribed, distress may respiratory rate
auscultate lung such as denote and depth with
sounds; oxygen by ET lessening air assistive
evaluate tube or exchange. respiratory
oxygen ventilator. aids in place.
saturation and
skin color.
Nurse Assess infant’s Maintain a A neutral Infant’s
axillary neutral thermal temperature is
temperature thermal environment maintained at
every hour. environment minimizes the 97.7°F
so infant’s risk of cold (36.5°C)
temperature stress, which axillary.
remains increases
stable. metabolic
demands for
oxygen.
Teamwork and Collaboration
Nurse/early intervention Determine Consult with Developmental Developmental
specialist/developmental what developmental care or trying care
care coordinator developmental care to reduce coordinator
care resources coordinator infant stress establishes an
will be regarding can improve individualized
available for specific infant’s program for
infant care. developmental outcome. infant care.
care measures
for infant.
Procedures/Medications for Quality Improvement
Nurse/neonatal nurse Assess infant’s Maintain ET The ET tube Respiratory
practitioner/primary care response to tube, protects a support
provider/respiratory respiratory mechanical patent airway. measures are
therapist support. ventilation, Mechanical in place, and
Assess oxygen and ventilation infant’s
saturation supplemental with warm respiratory rate
levels via warm humidified air remains within
pulse humidified assists with designated
oximetry. oxygen. delivering parameters.

1526
 Anticipate the necessary air
need for to the lungs
continuous and helps
positive prevent drying
airway of mucous
pressure membranes.
(CPAP) or
positive end-
expiratory
pressure
(PEEP).
Procedures/Medications for Quality Improvement
Nurse/primary medical Assess Administer Surfactant Surfactant
care provider availability of surfactant via restores the lavage is
surfactant for ET tube as per naturally administered.
administration. protocol. occurring lung Ventilatory
Refrain from surfactant to assistance is
suctioning for improve lung regulated as
1 hour if compliance. required.
possible. Suctioning
would remove
the drug from
its intended
site.
Nutrition
Nurse/nutritionist/primary Assess infant’s Administer Additional Infant tolerates
care provider need for nutrition via nutrients are enteral
nourishment enteral necessary feedings
based on feedings: because stress without
gestational age breast milk of respiratory difficulty.
and exhaustion supplemented distress Mother
from rapid with high- syndrome supplies breast
breathing. calorie (RDS) requires milk for
formula. increased feedings.
Anticipate the caloric
need for total expenditure.
parenteral Total
nutrition if parenteral
weight gain is nutrition may
not sufficient. be necessary to
meet these

1527
 additional
needs.
Nurse Assess blood Report Glucose is a Infant
glucose levels hypoglycemia source of maintains a
every 4 hours (blood energy. glucose level
by heel stick. glucose level Monitoring >45 mg/dl.
<45 mg/dl). glucose levels
helps to
determine if
sufficient
energy is
available to
meet the
newborn’s
metabolic
needs.
Patient-Centered Care
Nurse/primary care Assess what Teach parents Parents will Parents state
provider parents know the cause of need to work they are
about the preterm birth with adjusting to
cause of often cannot healthcare the shock of
preterm birth. be identified. team to preterm birth
arrange for based on better
best care for knowledge of
preterm infant. cause.
Psychosocial/Spiritual/Emotional Needs
Nurse/primary care nurse Assess what Invite parents Seeing, Parents visit in
activities to see, touch, touching, and nursery or
parents think and spend as caring promote telephone at
their very much time as attachment. least every
small infant possible with Guidance in other day and
can newborn. activities helps touch and talk
accomplish. Guide them in to alleviate to newborn.
activities such anxiety.
as skin-to-skin
contact and
basic
caregiving.
Nurse/NICU social Assess if Suggest A mobile or Parents state
worker parents have parents bring toy provides they know

1528
 worked in a mobile or visual preterm birth
through shock toy to keep stimulation is no one’s
of preterm near newborn. and promotes fault and
birth. feelings of express
participation in interest in
the newborn’s parenting.
care.
Informatics for Seamless Healthcare Planning
Nurse/NICU social Assess what Refer parents Parents may Parents give
worker community to helpful need continued examples of
organizations websites for support after how they are
will be preterm they return making active
available to information home with a plans for
family for and suggest small infant. infant’s
continued they join local discharge and
support. Parents of care.
Preemies
organization.

Prevention
RDS rarely occurs in mature infants. Dating a pregnancy by sonogram and by
documenting if the level of lecithin in surfactant obtained from amniotic fluid exceeds
that of sphingomyelin by a 2:1 ratio are both important ways to be certain an infant born
by cesarean birth or for whom labor is induced is mature enough that RDS is not likely
to occur.
Using a tocolytic agent such as magnesium sulfate can help prevent preterm birth
for a few days. During this time, if a woman receives two injections of a
glucocorticosteroid, such as betamethasone, it may be possible to prevent RDS in the
newborn because steroids appear to quicken the formation of lecithin. The
administration is most effective when given between weeks 24 and 34 of pregnancy.
Unfortunately, there is often no warning that preterm birth is imminent until hours
before birth. Because the steroid does not take effect before 24 to 48 hours, some labors
and births will progress too rapidly for this preventive measure to be effective.

QSEN Checkpoint Question 26.3

INFORMATICS
Baby Atkins has surfactant administered at birth. When Mrs. Atkins asks why her
baby had to receive surfactant, the nurse determines which response is best?
a. “Surfactant helps him raise his lung secretions by relaxing his airway.”

1529
 b. “Surfactant keeps his tiny lung sacs open and this improves his breathing.”
c. “Surfactant relaxes his respiratory muscles to synchronize his breathing
pattern.”
d. “Surfactant reduces the amount of lung secretions that he produces.”
Look in Appendix A for the best answer and rationale.

TRANSIENT TACHYPNEA OF THE NEWBORN

At birth, a newborn may have a rapid rate of respirations, up to 80 breaths/min when
crying, caused by retained lung fluid (Wyckoff et al., 2015).
Within 1 hour, however, this rapid rate slows to between 30 and 60 breaths/min. In
about 5 or 6 out of 1,000 live births, the respiratory rate doesn’t slow as a result of a
delayed absorption of alveolar fluid in the lungs. The infant does not appear to be in a
great deal of distress aside from the tiring effort of breathing. Mild retractions and some
nasal flaring may be noticed, enough to make feeding difficult because the infant cannot
suck and breathe this rapidly at the same time. A chest X-ray will reveal some fluid in
the lung along with hyperexpansion. Blood gases may show some respiratory acidosis,
hypercapnia, and hypoxemia (Hermansen & Mahajan, 2015).
Although transient tachypnea of the newborn (TTN) may reflect a slight decrease in
the production of phosphatidylglycerol or mature surfactant, it is a direct result of
retained lung fluid, which then limits the amount of alveolar surface that is available for
oxygen exchange. This limitation requires an infant to increase respiratory rate and
depth of respirations to better use the limited surface available. TTN occurs more often
in infants who are born by cesarean birth, in infants whose mothers received extensive
fluid administration during labor, and in preterm infants. Infants born by cesarean birth
are probably more prone to develop this form of respiratory distress because the
thoracic cavity is not compressed as it is in a vaginal birth, and so less lung fluid is
expelled.
Close observation of such a newborn is a priority. Watch carefully to be certain the
increased effort is not tiring and other signs of respiratory distress such as nasal flaring
or retractions are not occurring because a rapid respiratory rate is often the first sign of
respiratory obstruction. Other signs that suggest illness are grunting and difficulty
feeding. Oxygen administration may be necessary for some infants. Some infants will
be prescribed a mild glucosteroid to reduce respiratory tract inflammation. TTN usually
has an onset at about two hours of life and can last approximately 36 hours. The higher
the respiratory rate at onset, the longer TTN lasts. Treatment is supportive and typically
by 72 hours of life it resolves (Hermansen & Mahajan, 2015).

MECONIUM ASPIRATION SYNDROME

Meconium is present in the fetal bowel as early as 10 weeks of gestation. If hypoxia
occurs, a vagus reflex is stimulated, resulting in relaxation of the rectal sphincter. This
releases meconium into the amniotic fluid. Babies born breech may expel meconium

1530
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 20% of all births; in 2% to 4% of these births, infants
will aspirate enough meconium to cause meconium aspiration syndrome (MAS)
(Wyckoff et al., 2015). Meconium aspiration does not tend to occur in ELBW 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 (tachypnea, retractions, and grunting).
The infant may also require increased oxygen to maintain saturations in the mid to
upper 90s. This oxygen requirement usually starts in the first couple hours after birth
without any congenital anomalies that may cause the low oxygen saturations
(Lindenskov, Castellheim, Saugstad, et al., 2015).

Assessment
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). The Apgar score is apt to be
low. Almost immediately, tachypnea, retractions, and cyanosis begin. The infant should
be placed on the warmer, and resuscitation should begin including the initiation of
positive pressure ventilation as necessary (Wyckoff et al., 2015).
After the initiation of respirations, an infant’s respiratory rate may remain rapid
(tachypnea) and coarse bronchial sounds may be heard on auscultation. The infant may
continue to have retractions because the inflammation of bronchi tends to trap air in the
alveoli, limiting the entrance of oxygen. This air trapping may also cause enlargement
of the anteroposterior diameter of the chest (barrel chest). Pulse oximetry or blood gases
will reveal poor gas exchange evidenced by a decreased PO2 and an increased PCO2. A
chest X-ray will show bilateral coarse infiltrates in the lungs, with spaces of
hyperaeration (a peculiar honeycomb effect). The diaphragm will be pushed downward
by the overexpanded lungs.

Therapeutic Management
Amnioinfusion can be used to dilute the amount of meconium in the amniotic fluid and
has shown to improve the outcomes for the newborn with meconium in situations where
perinatal observation is limited. The benefits may be related to dilution of the meconium
or having an effect on the oligohydramnios (Hofmeyr, Xu, & Eke, 2014). If deeply
stained amniotic fluid is identified during labor, the infant may be scheduled for a
cesarean birth. After birth, infants may need to be treated with oxygen administration
and assisted ventilation. Antibiotic therapy may be prescribed to forestall the
development of pneumonia as a secondary problem. If lung compliance is poor,
surfactant may be administered (Wyckoff et al., 2015). If lung noncompliance

1531
continues, this may necessitate high inspiratory pressure. Unfortunately, this can cause a
pneumothorax or pneumomediastinum (air in the chest cavity). Observe the infant
closely, therefore, 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).
Yet, a further complication that can occur because of increased pulmonary
resistance is the ductus arteriosus remaining open, causing blood to shunt from the
pulmonary artery into the aorta and compromising cardiac efficiency and increasing
hypoxia. To detect this, observe an infant closely for signs of heart failure such as
increased heart rate or respiratory distress. Maintain a temperature-neutral environment
to prevent the infant from having to increase metabolic oxygen demands. A chest
physiotherapy with percussion and vibration may be helpful to encourage the removal
of remnants of meconium from the lungs (see Chapter 40). Some infants may need to be
administered nitric oxide or maintained on ECMO to ensure adequate oxygenation
(Chettri, Bhat, & Adhisivam, 2016).

APNEA
Apnea is a cessation in respirations lasting longer than 20 seconds, sometimes
accompanied by bradycardia and/or cyanosis. Many preterm infants have periods of
apnea as a result of fatigue or the immaturity of their respiratory mechanisms. Babies
with secondary stresses, such as infection, hyperbilirubinemia, hypoglycemia, or
hypothermia, tend to have a high incidence of apnea also (Thilo & Rosenberg, 2012).
Gently stimulating an infant or flicking the sole of the foot often causes the baby to
breathe again, almost as if the infant needed to be reminded to maintain this function. If
an infant does not respond to these simple measures, positive-pressure ventilation and
resuscitative interventions may be necessary.
Closely observe all newborns, especially preterm ones, to detect these apneic
episodes. Apnea monitors that record respiratory movements are invaluable tools to
detect apnea and sound a warning when an infant needs attention. Infants with frequent
or difficult-to-correct episodes may be placed on respiratory support (CPAP or
ventilator) until they are more mature.
To help prevent episodes of apnea, maintain a neutral thermal environment and use
gentle handling to avoid excessive fatigue. Always suction gently and only when
needed to minimize nasopharyngeal irritation, which can cause bradycardia because of
vagal stimulation. Using indwelling nasogastric tubes rather than intermittent ones can
also reduce the amount of vagal stimulation. After feeding, observe an infant carefully
because a full stomach can put pressure on the diaphragm and can potentially
compromise respirations. Careful burping also helps to reduce this effect. Never take
rectal temperatures in infants prone to apnea because the resulting vagal stimulation can
reduce the heart rate (bradycardia). Caffeine, a methylxanthine, may be prescribed for
apnea of prematurity to stimulate breathing (Kreutzer & Bassler, 2014). The mechanism
by which this medication reduces the incidence of apneic episodes is unclear, but they
appear to increase the infant’s sensitivity to carbon dioxide, which stimulates respiratory

1532
function. Infants who have had an apneic episode severe enough to require resuscitation
are at a high risk for sudden infant death syndrome. Such infants may be discharged
home with a monitoring device to be used for the first several months of life.

SUDDEN INFANT DEATH SYNDROME

Sudden infant death syndrome (SIDS) is a 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. Also prone to SIDS are
infants with BPD, twins, Native American infants, Alaskan Native infants,
economically disadvantaged Black infants, and infants of narcotic-dependent mothers.
The peak age of incidence is 2 to 4 months of age (AAP, 2011b).
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
• Brainstem 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 may report an infant had a
slight head cold. After being put to bed at night or for a nap, the infant is then 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 infants do not
suffocate from bedclothes or choke from overfeeding, underfeeding, or crying. Since the
AAP made the recommendation to put newborns to sleep on their back, the incidence of
SIDS has declined almost 50% to 60%. Other recommendations include the use of a
firm sleep surface; breastfeeding; room sharing without bed sharing; routine
immunizations; consideration of using a pacifier; and avoidance of soft bedding,
overheating, and exposure to tobacco smoke, alcohol, and illicit drugs (Byars & Simon,
2017). Although it was once thought having infants sleep with a fan in their room to
keep air moving might decrease the incidence of SIDS, the AAP has noted that,
currently, there is insufficient evidence to recommend the use of a fan as a SIDS risk-

1533
reduction strategy (AAP, 2011b).
Parents have a difficult time accepting the death of any child. This can be especially
difficult when it happens so suddenly and to an infant. 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 someone who is
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. The American
Sudden Infant Death Syndrome Institute, listed at the beginning of the chapter, offers
suggestions for counseling.
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 SIDS is a disease of
infants and 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 some children
wish siblings were dead occasionally, they need reassurance 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 until 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 first child.
A new baby born to a family in which a SIDS infant died can be screened using a
sleep assessment as a precaution within the first 2 weeks of life or, 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.

APPARENT LIFE-THREATENING EVENT

Some infants have been discovered cyanotic and limp in their beds but have survived
after mouth-to-mouth resuscitation by parents. This event, also referred to as an
apparent life-threatening event (ALTE) is characterized by a noticeable color change,
some degree of apnea, and decreased tone (Sahewalla, Gupta, & Kamat, 2016). For
these infants, as well as for preterm infants with a tendency toward apnea, or new babies
born to a family whose child died from SIDS, apnea monitoring may be prescribed.
With apnea monitoring in place, an alarm sounds when the infant experiences a period
of apnea of 20 seconds or longer or a decreased heart rate below 80 beats/min (or as
determined by the medical provider) (Fig. 26.10). If parents are going to use an apnea
monitor at home, make certain they will be able to hear it in all parts of the house or
apartment. Usually, for example, the alarm is not loud enough to be heard in the
basement from an upstairs bedroom. Caution parents about household noises such as a

1534
loud television, radio, vacuum cleaner, or hair dryer that may interfere with hearing the
alarm. Be certain they know how to apply and reposition the apnea leads and that they
are comfortable enough with the monitor to see past it to the infant. In addition, parents
should be taught infant cardiopulmonary resuscitation before their infant is discharged
from the hospital; reviewing the technique of this at healthcare visits is helpful (Fig.
26.11).

Figure 26.10 A home apnea monitor is used for this high-risk infant
during sleep to alert the parents of any apnea episodes. (From
Hatfield, N. T. [2014]. Introductory maternity & pediatric nursing [3rd
ed.]. Philadelphia, PA: Wolters Kluwer.)

Figure 26.11 Parents of infants with respiratory disorders need to

learn cardiac massage before their infant is discharged from the
hospital. Here, parents learn the technique using specialized dolls. (Ian
Miles, Flashpoint Pictures/Alamy.)

1535
 Caring for a child at home on an apnea monitor may be extremely stressful because
parents are often reluctant to leave the baby in someone else’s care for even a short time
or they have difficulty finding a competent babysitter. These parents can benefit from a
community or home care referral so they have a second opinion regarding how well
they are managing as well as a listening ear to discuss the strain of having to be
constantly alert for a sound that means their infant has stopped breathing. Having
someone periodically review with them what steps to take should the alarm sound (e.g.,
gently stimulate the baby, begin mouth-to-mouth resuscitation, call emergency response
personnel) can be very comforting.

QSEN Checkpoint Question 26.4

SAFETY
Baby Atkins is at risk for having apnea and bradycardia. What initial nursing
intervention should the nurse initiate during these events to maintain his vital signs in
a safe range?
a. Administer 2 drops (gtt) of oral theophylline by a small syringe into his
mouth.
b. Gently flick the sole of his foot to stimulate the baby to breathe again.
c. Monitor rectal temperatures to prevent him from becoming cold or hot.
d. Vigorously suction him every 2 hours to keep airway clear of secretions.
Look in Appendix A for the best answer and rationale.

PERIVENTRICULAR LEUKOMALACIA
Periventricular leukomalacia (PVL) is the result of ischemia of the white matter of
the brain (Gupta, Sodhi, Saxena, et al., 2016). It is caused by an anoxic episode that
interferes with circulation to a portion of the brain. Phagocytes and macrophages invade
the area to clear away necrotic tissue. What is left is an abnormality in the white matter
of the brain, which is revealed on a sonogram as a hollow space. PVL occurs most
frequently in preterm infants who experience cerebral ischemia. Once the condition has
occurred, there is no therapy. Infants may die of the original insult; they may be left
with long-term effects such as learning disabilities or cerebral palsy. Any action to
reduce environmental stimuli or sudden shifts in cerebral blood flow, such as avoiding
rapid fluid infusions or reducing pain, is important for preventing PVL and limiting this
long-term effect of prematurity (Alderliesten, Lemmers, Smarius, et al., 2013).

HEMOLYTIC DISEASE OF THE NEWBORN

(HYPERBILIRUBINEMIA)
The term “hemolytic” is Latin for “destruction” (lysis) of red blood cells. A certain
degree of lysis of red blood cells in the newborn results from the destruction of red
blood cells by a normal physiologic process as the newborn breaks down excess red

1536
blood cells formed in utero (see Chapter 18). Hemolytic disease is present when there is
excessive destruction of red blood cells, which leads to elevated bilirubin levels
(hyperbilirubinemia). In the past, hemolytic disease of the newborn was most often
caused by an Rh blood type incompatibility. Because the prevention of Rh antibody
formation has been available for almost 50 years, the disorder is now most often caused
by an ABO incompatibility. In both instances, because the fetus has a different blood
type than the mother, the mother builds antibodies against the fetal red blood cells,
leading to hemolysis of the cells, severe anemia, and hyperbilirubinemia.

Rh Incompatibility
In every pregnancy, a few red blood cells enter the maternal circulation. If the mother’s
blood type is Rh negative and the fetal blood type is Rh positive, this introduction of
fetal blood causes sensitization to occur and the woman to begin to form antibodies
against the specific antigen (most commonly the D antigen). Few antibodies actually
form this way during pregnancy, however. Most form in the woman’s bloodstream in
the first 72 hours after birth because there is an active exchange of fetal–maternal blood
as placental villi loosen and the placenta is delivered. Because of this surge in antibody
formation after a pregnancy, in a second pregnancy, there will be a high level of
antibody already circulating in the woman’s bloodstream. This will then act to destroy
the fetal red blood cells beginning early in the next pregnancy if the new fetus is Rh
positive, leading to the fetus being severely compromised by the end of that pregnancy.
Rh incompatibility is not commonly seen today because if Rh-negative women
receive Rho immune globulin (RHIG or RhoGAM) (passive Rh antibodies) within 72
hours after birth of an Rh-positive newborn, the process of antibody formation will be
halted and sensitization will not occur. The possibility Rh incompatibility could exist,
however, must be assessed for during pregnancy and again at birth because some
women (especially those who received prenatal care in another country) may not have
received RHIG following the birth or miscarriage of a former Rh-positive fetus.

ABO Incompatibility
In most instances of ABO incompatibility, the maternal blood type is O and the fetal
blood type is either A or B type blood.
Hemolysis can become a problem with a first pregnancy in which there is an ABO
incompatibility because the antibodies to A and B cell types are naturally occurring
antibodies or are present from birth in anyone whose red cells lack these antigens.
Fortunately, unlike the antibodies formed against the Rh D factor, these antibodies are
of the large (IgM) class and so do not cross the placenta. An infant of an ABO
incompatibility, therefore, is not born anemic, as the Rh-sensitized child could be.
Hemolysis of the blood begins with birth, when blood and antibodies are exchanged
during the mixing of maternal and fetal blood as the placenta is loosened; destruction
may continue for as long as 2 weeks. Interestingly, preterm infants do not seem to be

1537
affected by ABO incompatibility. This may be because the receptor sites for anti-A or
anti-B antibodies do not appear on red cells until late in fetal life. Even in the mature
newborn, a direct Coombs test may be only weakly positive because of the few anti-A
or anti-B sites present. The reticulocyte count (immature or newly formed red blood
cells) is usually elevated as the infant attempts to replace destroyed cells.

Assessment
Rh incompatibility of the newborn can be predicted by finding a rising anti-Rh titer or a
rising level of antibodies (indirect Coombs test) in a woman during pregnancy. It can be
confirmed by detecting antibodies on the fetal erythrocytes in cord blood (positive direct
Coombs test) by percutaneous umbilical blood sampling (see Chapter 9) or at birth. The
mother in this situation will always have Rh-negative blood, and the baby will be Rh
positive.
With Rh incompatibility, an infant may not appear pale at birth despite the red cell
destruction that occurred in utero because the accelerated production of red cells during
the last few months in utero compensates to some degree for the destruction. The liver
and spleen may be enlarged from attempts to destroy damaged blood cells. If the
number of red cells has significantly decreased, the blood in the vascular circulation
may be hypotonic to interstitial fluid, causing fluid to shift from the lower to higher
isotonic pressure by osmosis, resulting in extreme edema. Finally, the severe anemia
can result in heart failure as the heart has to beat at a faster rate than normal to push the
diluted blood forward. Hydrops fetalis is a Greek term that refers to a pathologic
accumulation of at least two or more cavities with a collection of fluid in the fetus.
Most infants do not appear jaundiced at birth because the maternal circulation has
evacuated the rising indirect bilirubin level. With birth, progressive jaundice, usually
occurring within the first 24 hours of life, will begin, indicating in both Rh and ABO
incompatibility that a hemolytic process is occurring. The jaundice occurs because, as
red blood cells are destroyed, indirect bilirubin is released. Indirect bilirubin is fat-
soluble and cannot be excreted from the body. Under usual circumstances, the liver
enzyme glucuronyl transferase converts indirect bilirubin to direct bilirubin. Direct
bilirubin is water-soluble and combines with bile for excretion from the body through
feces. In preterm infants or those with extreme hemolysis, the liver cannot convert all of
the indirect bilirubin produced into direct bilirubin fast enough, so jaundice occurs.
Normally, cord blood has a total serum bilirubin (TsB) level of 0 to 3 mg/100 ml.
An increasing bilirubin level becomes dangerous if the level rises above 20 mg/dl in a
term infant and perhaps as low as 12 mg/dl in a preterm infant because brain damage
from bilirubin-induced neurologic dysfunction (BIND), a wide spectrum of disorders
caused by increasingly severe hyperbilirubinemia ranging from mild dysfunction to
acute bilirubin encephalopathy (ABE) (invasion of bilirubin into brain cells), can occur.
A second concern that arises from excessive red blood cell destruction is that an infant
is forced to use glucose stores to maintain metabolism in the presence of anemia. This
can cause a progressive hypoglycemia, compounding the initial problem. A decrease in

1538
hemoglobin during the first week of life to a level less than that of the cord blood is a
later indication of blood loss or hemolysis.

Therapeutic Management
Bilirubin levels in blood may be measured by either a blood draw (TsB) or by holding a
transcutaneous meter against the infant’s skin (transcutaneous bilirubin [TcB]). The
initiation of early feeding (urge mothers to breastfeed 8 to 10 times a day for the first 2
days), use of phototherapy, and exchange transfusion all may be measures necessary to
reduce the TsB level in an infant affected by a blood incompatibility. In infants with
severe hemolytic disease, the hemoglobin concentration can continue to drop during the
first 6 months of life, or their bone marrow may fail to increase production of
erythrocytes in response to continuing hemolysis so they need an additional blood
transfusion to correct this late anemia. Therapy with erythropoietin to stimulate red
blood cell production is also possible (Wüest, Manser, Küster, et al., 2016)

The Initiation of Early 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
(either breast milk or formula), therefore, stimulates bowel peristalsis and helps to
accomplish this.

Phototherapy
A fetus’s liver processes little bilirubin in utero because the mother’s circulation does
this for the fetus. With birth, exposure to light is believed to trigger 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. Phototherapy
exposes the infant to continuous specialized light such as quartz halogen, cool white
daylight, or special blue fluorescent light. The lights are placed 12 to 30 in. above the
newborn’s bassinet or incubator.
Term newborns are generally scheduled for phototherapy when the TsB level rises
to 10 to 12 mg/dl at 24 hours of age; preterm infants may have treatment begun at levels
lower than this (Bhardwaj, Locke, Biringer, et al., 2017). Although the results of the
therapy are mixed, the administration of intravenous immunoglobulin (IVIG) has been
used in neonates with hemolytic disease in combination with phototherapy, especially in
ABO incompatibility to try and extenuate the effect of phototherapy (Keir, Dunn, &
Callum, 2013).
Continuous exposure to bright lights by phototherapy may be harmful to a
newborn’s retina, so the infant’s eyes must always be covered while under bilirubin
lights. Commercial phototherapy masks or eye coverings must be used at all times when
the infant is under phototherapy (with the use of bilirubin blankets, eye protection is not
usually necessary if it is a full-term newborn). Check the eye covering/mask frequently

1539
to be certain it has not slipped. Infants are most apt to dislodge the eye covering when
they cry as they wake for a feeding. Urge parents to respond quickly, therefore, if the
infant is in their postpartum room to avoid eye damage and possible suffocation by the
infant pushing the eye covering down over the nose (Fig. 26.12).

Figure 26.12 A newborn receiving phototherapy is undressed except

for a diaper so he receives maximum exposure to the lights. His eyes
are covered snugly to protect them from the ultraviolet light.

The stools of an infant under bilirubin lights are often bright green because of the
excessive bilirubin being excreted as the result of the therapy. They are also frequently
loose and may be irritating to the skin. Urine may be dark colored from urobilinogen
formation. Monitor the infant’s axillary temperature to prevent him or her from
overheating under the bright lights. Assess skin turgor and intake and output to ensure
dehydration is not occurring from the warm environment.
Infants receiving phototherapy should be removed from under the lights for feeding
so they continue to have interaction with their mother. Remove the eye patches while
the infant is out from under the lights for a period of visual stimulation. To prevent a
lengthy hospital stay, infants may be discharged and continue therapy at home.
Specialized fiber optic light systems incorporated into a fiber optic blanket also have
been developed and are ideal for home care. The light generated by the blanket has the

1540
same effect on bilirubin levels as banks of overhead lights. The infant is undressed
except for a diaper to protect the ovaries or testes and so as much skin surface as
possible is exposed to the light. Two big advantages are that an infant can be held for
long periods without interrupting the phototherapy, and eye patches are unnecessary.
Parents need an explanation of the rationale for phototherapy and why their infant
needs it. Although phototherapy has not been used long enough that long-term effects
can be studied, there appears to be minimal risk to an infant from the procedure,
provided the infant’s eyes remain covered and dehydration from increased insensitive
water loss does not occur. Even though there is no evidence so far that infants who
received phototherapy are at greater risk for developing skin cancer, all infants who
receive phototherapy should (as should all infants) have sunscreen applied when they
are in the sun and follow-up assessments in coming years to detect skin cancer that
possibly could occur from the therapy (Oláh, Tóth-Molnár, Kemény, et al., 2013).

Exchange Transfusion
The use of intensive phototherapy in conjunction with hydration and close monitoring
of serum bilirubin levels has greatly reduced the need for exchange transfusions. If this
is done, small amounts (2 to 10 ml) of the infant’s blood are drawn from the infant’s
umbilical vein and then replaced with equal amounts of donor blood. The therapy may
be used for any condition that leads to hyperbilirubinemia or polycythemia. When used
as therapy for blood incompatibility, it removes approximately 85% of sensitized red
cells. It reduces the serum concentration of indirect bilirubin and can prevent heart
failure in infants with severe anemia or polycythemia.
A transfusion should be done under a radiant heat warmer to keep the infant warm
during what can be a lengthy procedure to prevent energy expenditure from having to
maintain body temperature. Donor blood must be maintained at room temperature, or
hypothermia from the cold insult could result. Use only commercial blood warmers to
warm blood, not hot towels or a radiant heat warmer, to avoid destroying red cells.
The type of blood used for transfusion is O Rh-negative blood, even if an infant’s
blood type is positive; if Rh-positive or type A or B blood were given, the maternal
antibodies that entered the infant’s circulation would destroy this blood also, and the
transfusion would be ineffective. If the baby will be transported to a regional center for
the exchange transfusion, a sample of the mother’s blood should accompany the infant,
so cross-matching on the mother’s serum can be done there.
After a transfusion, closely observe the infant to be certain vital signs are stable and
there is no umbilical vessel bleeding or inflammation of the cord if this was the
transfusion site, which would suggest infection. Report any changes in vital signs.
Monitor bilirubin levels for 2 or 3 days after the transfusion to ensure the level of
indirect bilirubin is not rising again and that no further phototherapy or transfusion is
necessary.

TWIN-TO-TWIN TRANSFUSION

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Twin-to-twin transfusion is a phenomenon that can occur if twins are monozygotic
(identical; share the same placenta) and abnormal arteriovenous shunts occur that direct
more blood to one twin than the other (Swiatkowska-Freund, Pankrac, & Preis, 2012).
The process occurs in as many as one third of all identical twin pregnancies, although
enough blood is exchanged to be clinically important in only about 15% of such
pregnancies. The result of this shift of blood leads to anemia in the donor twin and
polycythemia in the receiving twin. The anemic twin may also be pale and SGA
because of the lack of nutrients or oxygen for growth as well as hypoglycemic from lack
of glucose stores. The polycythemic twin is prone to hyperbilirubinemia as the
excessive red blood cell level is broken down.
Twin-to-twin transfusion can be identified in utero by a sonogram because one twin
is noticeably larger than the other. All identical twins should have hemoglobin
determinations done at birth and the results should be compared. A hemoglobin
difference of more than 5.0 g/100 ml is enough to suggest a transfusion between the
twins has occurred. Each twin needs therapy as indicated by the extent of the blood
distribution. The donor twin may need a transfusion to establish a functioning blood cell
level, and the recipient twin may need an exchange transfusion to reduce the
polycythemia and viscosity of the blood.

QSEN Checkpoint Question 26.5

QUALITY IMPROVEMENT
The nurse is concerned that Baby Atkins will develop hyperbilirubinemia because of
his immaturity. Because the prevention of jaundice is one of the NICU’s quality
indicators, what priority nursing intervention would the nurse initiate to best prevent
hyperbilirubinemia in Baby Atkins?
a. Administering phenobarbital to all infants to help prevent jaundice
b. Urging all mothers to breastfeed early to promote infants’ bowel motility
c. Placing all preterm and SGA infants in warm, dark, comforting environments
d. Immediately placing all infants under phototherapy following birth
Look in Appendix A for the best answer and rationale.

NECROTIZING ENTEROCOLITIS
Necrotizing enterocolitis (NEC) is a gastrointestinal disease. Premature newborns are at
the greatest risk for developing the disease, with approximately 5% of all infants
developing it in intensive care nurseries (Pun, Jones, Wolfe, et al., 2016). The bowel
develops necrotic patches, interfering with digestion and possibly leading to a paralytic
ileus, perforation, and peritonitis. It occurs because of anoxia to the bowel and so may
result as a complication of exchange transfusion or an episode of breathing difficulty.
Because it shares common features with other gastrointestinal disorders, it is discussed
in Chapter 45.

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RETINOPATHY OF PREMATURITY
Retinopathy of prematurity (ROP), an acquired ocular disease that leads to partial or
total blindness in children, is caused by vasoconstriction of immature retinal blood
vessels. It was first recognized as an eye disorder in 1942, but only later was a high
concentration of oxygen established as the causative agent (Fleck & Stenson, 2013).
Immature retinal blood vessels constrict when exposed to high oxygen concentrations;
endothelial cells in the periphery of the retina then proliferate, causing retinal
detachment and possible blindness. Infants who are most immature and most ill (and
consequently receive the most oxygen) are at the highest risk for developing ROP.
When blood Po2 levels rise to higher than 100 mmHg, the risk of the disease
increases greatly. Based on this, all preterm infants who receive oxygen must have
blood oxygen levels monitored by pulse oximeter or blood gas monitoring so the blood
Po2 level can be regulated within normal limits.
In the past, once ROP occurred, there was no reversing it. Today, cryosurgery or
laser therapy may be effective at preserving sight. A person experienced in recognizing
ROP should examine the eyes of all babies who have received oxygen (especially LBW
newborns) before discharge from a hospital nursery and again at 4 to 6 weeks of age to
detect any occurrence of the syndrome. Nurses can be instrumental in limiting the
occurrence of ROP by securing oxygen saturation levels and by the conscientious
management of oxygen (Martínez-Castellanos, Schwartz, Hernández-Rojas, et al.,
2013).

The Newborn at Risk Because of a Maternal Infection

Newborns are susceptible to infections during pregnancy and at birth because their
ability to produce antibodies is immature. A number of infections in newborns, such as
toxoplasmosis, rubella, syphilis, and cytomegalovirus infections, spread to the fetus
across the placenta in utero and are discussed in Chapter 12 with other complications of
pregnancy. Other infections, such as those discussed in the following sections, are not
contracted in utero but are contracted from exposure to vaginal secretions at birth.

β-HEMOLYTIC, GROUP B STREPTOCOCCAL INFECTION

A serious cause of infection in newborns is the gram-positive β-hemolytic, group B
streptococcal (GBS) organism, a natural inhabitant of the female genital tract. Between
50 and 300 infants out of every 1,000 live births display a positive culture for the
organism (AAP, 2011a). It also may be spread from baby to baby if good hand washing
technique is not used in caring for newborns. If a woman is found to be positive for
GBS during late pregnancy (see Chapter 21), ampicillin administered IV during
pregnancy and again during labor helps to reduce the possibility of newborn exposure.

Assessment

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Universal screening is recommended for pregnant women at 35 to 37 weeks of gestation
to see if they have GBS organisms in their vaginal secretions (Albright, MacGregor,
Sutton, et al., 2017). Typically, a newborn at risk, such as one born after prolonged
rupture of membranes or if the woman’s vaginal culture is positive for GBS, will be
screened at birth for infection by a specialized GBS blood culture.
Colonization by GBS can result in either an early-onset or a late-onset illness. With
the early-onset form, signs of pneumonia such as tachypnea, apnea, extreme paleness,
hypotension, or hypotonia become apparent within the first day of life. Decreased urine
output can occur from the hypotension. A chest X-ray may not be diagnostic because
the changes seen are almost indistinguishable from those of RDS (a ground-glass
appearance). Without therapy, the disease progresses so rapidly, as many as 20% of
infants who contract the infection die within 24 hours of birth.
A late-onset type occurs at 2 to 4 weeks of age. With this, instead of pneumonia
being the infection focus, meningitis tends to occur. Typical signs include lethargy,
fever, loss of appetite, and bulging fontanelles from increased intracranial pressure.
Mortality from the late-onset type is not as high as that from the early-onset form (15%
vs. 20%), but neurologic consequences can occur in up to 50% of infants who survive.

Therapeutic Management
If a newborn displays signs of infection or a blood screening test is positive, antibiotics
such as penicillin, cefazolin, clindamycin, or vancomycin are all effective against the
GBS organism.
Parents may have difficulty understanding how their infant could suddenly have
become this ill, and they may need a great deal of support to care for their infant. This is
even more important if the newborn survives the infection but is left neurologically
challenged. In the future, immunization of all women of childbearing age against
streptococcal B organisms could decrease the incidence of newborns infected at birth.

OPHTHALMIA NEONATORUM
Ophthalmia neonatorum is an eye infection that occurs at birth or during the first
month of life (Matejcek & Goldman, 2013). The most common causative organisms are
Neisseria gonorrhoeae and Chlamydia trachomatis, which are contracted from vaginal
secretions. An N. gonorrhoeae infection is an extremely serious form of infection
because, if left untreated, the infection progresses to corneal ulceration and destruction,
resulting in opacity of the cornea and severe vision impairment.

Assessment
Ophthalmia neonatorum is generally bilateral. The conjunctivae become fiery red and
covered with thick pus. The eyelids appear edematous. Although this usually occurs on
day 1 to day 4 of life, it should be considered as a possibility when conjunctivitis occurs
in any infant younger than 30 days of age.

1544
Prevention
The prophylactic instillation of erythromycin ointment into the eyes of newborns
prevents both gonococcal and chlamydial conjunctivitis. In the past, eye prophylaxis
was given immediately after birth so it was never forgotten. Now it is more customary
to delay the administration of the ointment until after the first reactivity period so the
newborn can clearly see the parents during this important attachment period. This
makes it easy for administration to be forgotten, so use some type of a checklist as a
reminder of this important prophylaxis. Infants born outside the hospital also need
prophylaxis to prevent ophthalmia neonatorum, the same as for infants born in a
birthing room.

Therapeutic Management
If conjunctivitis occurs, therapy is individualized depending on the organism cultured
from the exudate. If gonococci are identified, intravenous ceftriaxone (Rocephin) and
penicillin are effective drugs. If Chlamydia is identified, an ophthalmic solution of
erythromycin is commonly used.
Use standard and contact infection precautions when caring for this newborn. In
addition to systemic antibiotic therapy, sterile saline solution lavage to clear the copious
discharge from the eyes may be prescribed. When irrigating eyes, use a sterile medicine
dropper or bulb syringe and use barrier protection, including goggles to avoid splashing
any solution into your own eye. The solution should be at room temperature. Direct the
stream of the irrigation fluid laterally so it does not enter and contaminate the other eye.
The mother of the infected infant needs treatment for gonorrhea or chlamydia before
fallopian tube sterility or pelvic inflammatory disease can result. Sexual contacts of the
mother should be treated also so the spread of the disease can be halted. With either
infection, parents can be assured with early diagnosis and treatment that the prognosis
for normal eyesight in their child is good.

HEPATITIS B VIRUS INFECTION

Hepatitis B virus (HBV) can be transmitted to the newborn through contact with
infected vaginal blood at birth when the mother is positive for the virus (positive for the
surface antigen of the hepatitis B virus [HBsAg+]). Hepatitis B is a destructive illness
with greater than 90% of infected infants becoming chronic carriers of the virus as well
as the risk of developing liver cancer later in life (Ni, 2011). To reduce the possibility of
HBsAg being spread to newborns in the future, parents are asked if they would like their
infant vaccinated against hepatitis B at birth (Kurosky, Davis, & Krishnarajah, 2016).
If the mother is identified as HBsAg+, her infant should be bathed as soon as
possible after birth to remove HBV-infected blood and secretions. Gentle suctioning is
necessary to avoid trauma to the mucous membrane, which could allow HBV invasion.
To further protect against infection, the infant is administered serum hepatitis B immune
globulin (HBIG) in addition to the HBV vaccination. Although the virus is transmitted

1545
in breast milk, once immune globulin has been administered, women may breastfeed
without risk to an infant. Hepatitis B is further discussed in Chapter 45 because it shares
common symptoms with other liver disorders and also occurs in older children.

GENERALIZED HERPESVIRUS INFECTION

A herpes simplex virus type 2 (HSV-2) infection, which is most prevalent among
women with multiple sexual partners, can be contracted by a fetus across the placenta if
the mother has a primary infection during pregnancy. More often, however, the virus is
contracted from the vaginal secretions of a mother who has active herpetic
vulvovaginitis at the time of birth. Between 15% and 30% of women of childbearing
age demonstrate antibodies to this virus or have the potential to have active lesions
during labor (Looker, Magaret, May, et al., 2017).

Assessment
If the infection was acquired during pregnancy, an infant may be born with vesicles
covering the skin. The long-term prognosis of the child is guarded because severe
neurologic damage may have occurred simultaneously with the development of the
lesions. If infants don’t acquire the infection until birth, by day 4 to day 7 of life, they
show a loss of appetite, perhaps a low-grade fever, and lethargy. Stomatitis (ulcers of
the mouth) or a few vesicles on the skin appear. Herpes vesicles always cluster, are
pinpoint in size, and are surrounded by a reddened base. After the vesicles appear,
infants become extremely ill. They develop dyspnea, jaundice, purpura, convulsions,
and hypotension. Death may occur within hours or days. Between 25% and 70% of
newborns who survive generalized herpesvirus infections have permanent central
nervous system sequelae (Pinninti & Kimberlin, 2014).
To confirm the diagnosis, cultures are obtained from representative vesicles as well
as from the nose, throat, anus, and umbilical cord. Blood serum is analyzed for IgM
antibodies.

Therapeutic Management
An antiviral drug such as acyclovir (Zovirax), a drug that inhibits viral DNA synthesis,
is effective in combating this overwhelming infection. Prevention, however, is the
newborn’s best protection. Antenatal antiviral prophylaxis reduces viral shedding and
recurrences at birth and reduces the need for cesarean birth (Pinninti & Kimberlin,
2014). Women with active herpetic vulvar lesions are advised to have cesarean birth
rather than vaginal birth to minimize the newborn’s exposure. Infants with an infection
should be separated from other infants in a nursery. Although transmission from this
source is rare, women with herpes lesions on their face (herpes simplex I, or cold sores)
need to be assessed before they hold their newborns to be sure lesions are crusted and,
therefore, are no longer contagious. Healthcare personnel who have herpes simplex
infections should not care for newborns until the lesions are crusted. Although facial

1546
herpes simplex lesions are probably caused by herpesvirus type 1, limiting contact does
not seem excessive in light of the severity of HSV-2 disease. Urge a woman who is
separated from her newborn at birth to view her infant from the nursery window and
participate in planning care to aid bonding.

HIV INFECTION
HIV infection and AIDS can be caused by placental transfer or direct contact with
maternal blood during birth. Because older children can also be exposed to this disease,
the care of children with this infection is discussed in Chapter 42.

The Newborn at Risk Because of a Maternal Illnesses

AN INFANT OF A WOMAN WHO HAS DIABETES MELLITUS
Infants of women who have diabetes mellitus whose illness was poorly controlled
during pregnancy are typically longer and weigh more than other babies (macrosomia).
The baby also has a greater chance of having a congenital anomaly such as a cardiac
anomaly because hyperglycemia is teratogenic to a rapidly growing fetus.
Most such babies have a cushingoid (i.e., fat and puffy) appearance. They tend to be
lethargic or limp in the first days of life as a result of hyperglycemia. The macrosomia
results from overstimulation of pituitary growth hormone and extra fat deposits created
by high levels of insulin during pregnancy. This infant’s large size is deceptive,
however, because, like all LGA babies, they are often immature. RDS occurs at a higher
rate than usual in these infants because they may be born preterm or, if born at term,
lecithin pathways may not be mature. High fetal insulin secretion during pregnancy to
counteract the hyperglycemia can interfere with cortisol release. This could block the
formation of lecithin and further prevent lung maturity (Murphy, Janzen, Strehlow, et
al., 2013). A term frequently used for these infants is “fragile giant.”
An infant of a woman with diabetes loses a greater proportion of weight in the first
few days of life than does the average newborn because of the loss of extra fluid
accumulated. Observe such an infant closely to be certain this weight loss actually
represents a loss of extra fluid and that dehydration is not occurring.

Complications
A macrosomic infant has a greater chance of birth injury, especially shoulder and neck
injury. A cesarean birth may be necessary to avoid cephalopelvic disproportion.
Immediately after birth, the infant tends to be hyperglycemic because the mother was at
least slightly hyperglycemic during pregnancy and excess glucose transfused across the
placenta. During pregnancy, the fetal pancreas responded to this high glucose level with
islet cell hypertrophy, resulting in matching high insulin levels. After birth, as an
infant’s glucose level begins to fall because the mother’s circulation is no longer
supplying glucose, the overproduction of insulin will cause the development of severe

1547
hypoglycemia. Hyperbilirubinemia also may occur in these infants because, if
immature, they cannot effectively clear bilirubin from their system. Hypocalcemia also
frequently develops because parathyroid hormone levels are lower in these infants due
to hypomagnesemia from excessive renal losses of magnesium.
Although infants of women with diabetes are usually LGA, an infant born to a
woman with extensive blood vessel involvement may be SGA because of poor placental
perfusion. The problems of hypoglycemia, hypocalcemia, and hyperbilirubinemia
remain the same.

Therapeutic Management
In a newborn, hypoglycemia is defined as a serum glucose level of less than 45 mg/dl.
To avoid a serum glucose level from falling this low, infants of women with diabetes
need to be fed early; if they are unable to suck, a continuous infusion of glucose can be
prescribed. It is important the infant not be given only a bolus of glucose; otherwise,
rebound hypoglycemia (accentuating the problem) can occur. Some infants of women
with diabetes have a smaller than usual left colon, apparently another effect of
intrauterine hyperglycemia, which can limit the amount of oral feedings they can take in
their first days of life. Signs of an inadequate colon include vomiting or abdominal
distention after the first few feedings. Careful monitoring for any vomiting and normal
bowel movements can help identify this condition.

QSEN Checkpoint Question 26.6

PATIENT-CENTERED CARE
Mrs. Atkins asks the nurse why the baby in the incubator next to her baby whose
mother has diabetes mellitus was fed so soon after birth. Why is it important for
infants of women with diabetes to be fed early?
a. Their stomach is larger than usual due to overgrowth.
b. This helps prevent rebound hypoglycemia from occurring.
c. The mother probably didn’t eat much during her labor.
d. This helps clear thick mucus from the lower intestinal tract.
Look in Appendix A for the best answer and rationale.

AN INFANT OF A DRUG-DEPENDENT MOTHER

Infants of drug-dependent women tend to be SGA. If the woman took a drug close to
birth, her infant may show withdrawal symptoms (neonatal abstinence syndrome)
shortly after birth (Box 26.9). These include such signs as:
• Irritability
• Disturbed sleep pattern
• Constant movement, possibly leading to abrasions on the elbows, knees, or nose
• Tremors

1548
 • Frequent sneezing
• Shrill, high-pitched cry
• Possible hyperreflexia and clonus (neuromuscular irritability)
• Convulsions
• Tachypnea (rapid respirations), possibly so severe that it leads to
hyperventilation and alkalosis
• Vomiting and diarrhea, leading to large fluid losses and secondary dehydration

BOX 26.9
Nursing Care Planning Using Assessment

ASSESSING THE NEWBORN OF A DRUG-DEPENDENT MOTHER

Specific neonatal abstinence scoring tools can be used to quantify and assess an
infant’s status. When symptoms begin to appear and when they fade varies with the
drug involved, but, on average, symptoms occur in 24 to 48 hours and last about 2
weeks. The infants of women who were on methadone maintenance during pregnancy
will show the same beginning and length of symptoms. The abstinence sequence for the
cocaine-addicted neonate is usually milder, but factors such as maladaptive coping
behaviors may be present in such newborns into preschool (Buckingham-Howes,
Berger, Scaletti, et al., 2013).

1549
 Narcotic metabolites or quinine (heroin is often mixed with quinine) may be
obtained from an infant’s urine or meconium in the first hour after birth to establish that
the drug was transferred into the infant before birth. These products are quickly cleared
from the body, however, so by the time symptoms become severe, detection of narcotic
substances may no longer be possible. Cocaine, in contrast, may be detected in infants’
hair samples for an extended time.
Infants of drug-dependent women usually seem most comfortable when firmly
swaddled. Keep them in an environment free from excessive stimuli (a small isolation
nursery or the mother’s room, not a large, open nursery). Some quiet best if the room is
darkened. Some may suck vigorously and continuously and seem to find comfort and
quiet if given a pacifier. In contrast, infants of methadone- and cocaine-addicted women
may have extremely poor sucking ability and may have difficulty achieving sufficient
fluid intake unless gavage fed. Unless a woman intends to remain drug free, she is
usually advised not to breastfeed to avoid passing narcotics in breast milk to the infant.
Specific therapy for an infant has to be individualized according to the nature and
severity of the signs. If an infant has vomiting or diarrhea, intravenous administration of
fluid may be indicated. The most common medications to counteract abstinence
symptoms are morphine and methadone (Bagley, Wachman, Holland, et al., 2014).
Other drugs that may be used include methadone, chlorpromazine (Thorazine), and
diazepam (Valium). These are typically used if the neonatal abstinence scoring system
average score is elevated on three successive occasions and other nursing interventions
do not reduce the score.
Once an infant has been identified as having been exposed to drugs in utero, the
mother needs treatment for withdrawal symptoms and follow-up care as much as the
infant. In addition, an evaluation is necessary to determine before discharge from the
healthcare facility whether an environment that allowed for drug abuse will be safe for
an infant at home (Bagley et al., 2014). Infants also need long-term follow-up because
long-term neurologic problems may develop.

AN INFANT WITH FETAL ALCOHOL EXPOSURE

Alcohol crosses the placenta in the same concentration as is present in the maternal
bloodstream so may result in fetal alcohol exposure, or fetal alcohol spectrum
disorder (Tsai, Manchester, & Elias, 2012). The disorder appears in about 2 out of
1,000 newborns and is often more difficult to document than recreational drug exposure
because alcohol abuse may be more difficult to document. Because alcohol has serious
deteriorating effects on the placenta and it is unknown if there is a safe threshold of
alcohol ingestion during pregnancy, all pregnant women are advised to avoid alcohol
intake to prevent any teratogenic effects on their newborn (Dunney, Muldoon, &
Murphy, 2015).
A newborn with fetal alcohol spectrum disorder has several possible problems at
birth. Characteristics that mark the syndrome include prenatal and postnatal growth
restriction; central nervous system involvement such as cognitive challenge,

1550
microcephaly, and cerebral palsy; and a distinctive facial feature of a short palpebral
fissure and thin upper lip. During the neonatal period, an infant may appear tremulous,
fidgety, and irritable and may demonstrate a weak sucking reflex. Sleep disturbances are
common, with the baby tending to be either always awake or always asleep depending
on the mother’s alcohol level close to birth.
The most serious long-term effect is cognitive challenge. Behavior problems such as
hyperactivity may occur in school-age children. Growth deficiencies may remain
throughout life. An infant needs conscientious follow-up so any future problems can be
discovered. The mother needs a follow-up to see if she can reduce her alcohol intake for
better overall health (Cook, Green, Lilley, et al., 2016)

What If . . . 26.4
The nurse is interested in exploring one of the 2020 National Health Goals
with respect to high-risk newborns (see Box 26.1). Most government-sponsored
money for nursing research is allotted based on these goals. What would be a
possible research topic to explore pertinent to these goals that would be
applicable to the Atkins family and that would also advance evidence-based
practice?

KEY POINTS FOR REVIEW

Priorities for infants born with special needs, such as preterm or postterm infants, are
the same as for term infants: initiation and maintenance of respirations,
establishment of extrauterine circulation, control of body temperature, intake of
adequate nourishment, establishment of waste elimination, establishment of an
infant–parent relationship, prevention of infection, and provision of developmental
care for mental and social development.
Many high-risk infants need resuscitation at birth. Prompt action with such measures
as warmth, oxygen, intubation, and suctioning are needed.
An SGA infant is one whose birth weight is below the 10th percentile on an
intrauterine growth curve for that gestational age infant. An infant could be born
preterm, term, or postterm. They typically have difficulty maintaining body warmth
because of low fat stores and may develop hypoglycemia from low glucose stores.
An LGA infant is one whose birth weight is above the 90th percentile on an
intrauterine growth chart for that gestational age. The infant could be born preterm,
term, or postterm. They tend to be infants of women with diabetes, and they are
particularly prone to hypoglycemia or birth trauma.
An early preterm infant is one born between 24 and 34 weeks of gestation; a late
preterm infant is one born between 34 and 37 weeks of gestation. Preterm infants
have particular problems with respiratory function, anemia, jaundice, persistent
patent ductus arteriosus, and intracranial hemorrhage.

1551
Infants who are born weighing less than 2,500 g at birth are termed low–birth-weight
infants, those born weighing less than 1,500 g are termed very-low-birth-weight
infants, and those born weighing less than 1,000 g are extremely low–birth-weight
infants. Most of these infants need intensive care from the moment of birth to give
them their best chance of survival.
A postterm infant is one who has remained in utero past week 42 of pregnancy.
Postterm infants have particular problems with establishing respirations, meconium
aspiration, hypoglycemia, temperature regulation, and polycythemia.
RDS commonly occurs in preterm infants from a deficiency or lack of surfactant in
the alveoli. Without surfactant, the alveoli collapse on expiration and require extreme
force for reinflation. Primary therapy is synthetic surfactant replacement at birth,
followed by oxygen and ventilatory support.
TTN is a temporary condition caused by the slow absorption of lung fluid at birth. It
is seen most often in infants born by cesarean birth. Close observation of the infant is
necessary until the fluid is absorbed and respirations slow to a usual rate.
MAS occurs when an infant aspirates meconium-stained amniotic fluid before or
during birth. Meconium is irritating to the airway and so leads to both airway spasm
and pneumonia. Infants need oxygen, ventilatory support, and possibly an antibiotic
until the effects of the insult to the airway subside
Apnea is a pause in respirations longer than 20 seconds and may be accompanied by
bradycardia. It tends to occur in preterm infants who have secondary stresses such as
an infection, hyperbilirubinemia, hypoglycemia, or hypothermia. Apnea monitors are
used to detect this, and infants who are at high risk for apnea may be discharged with
a home monitoring program.
SIDS is the sudden, unexplained death of an infant. It is associated with infants
sleeping on their stomachs (prone) and infants born preterm. An important
preventive measure is advising parents to position their infant on the back and
possibly use a pacifier for sleeping.
Hyperbilirubinemia results from the destruction of red blood cells, owing either to a
usual physiologic response or an abnormal destruction of red blood cells. Hemolytic
disease of the newborn occurs from destruction of red blood cells from Rh or ABO
incompatibility. The administration of RHIG (Rh antibodies) to Rh-negative mothers
during pregnancy and after the birth of an Rh-positive infant to an Rh-negative
mother has greatly reduced the incidence of the condition. Affected infants appear
jaundiced from the release of bilirubin from injured red blood cells. Phototherapy
and an exchange transfusion are used to prevent ABE (the deposition of bilirubin in
brain cells, causing destruction of the cells).
Hemorrhagic disease of the newborn is a lack of clotting ability resulting from a
deficiency of vitamin K at birth. This disorder is prevented by administering vitamin
K to a newborn within the first hour following birth.
ROP is destruction of the retina caused by exposure of immature retinal capillaries to
high levels of oxygen. Monitoring oxygen saturation by pulse oximetry or ABGs are

1552
 important preventive measures and help in planning nursing care that not only meets
QSEN competencies but that also best meets a family’s total needs.
Severe infections acquired by infants at birth include streptococcal group B
pneumonia, hepatitis B infection, ophthalmia neonatorum (gonococcal and
chlamydial conjunctivitis), and herpesvirus infections. Assessing newborns for
symptoms of these infections is an important nursing responsibility.
Infants of women with diabetes and those of drug-abusing women are at high risk at
birth for further complications. Both need a careful assessment for respiratory
distress and hypoglycemia.

CRITICAL THINKING CARE STUDY

Priscilla Angelini is an unmarried 17-year-old who has just given birth via cesarean
birth to her first baby, a girl, at 37 weeks of gestation because of a breech
presentation. Priscilla did not receive any prenatal care. At birth, she tests positive for
group B streptococcal infection. When assessing her newborn, you conclude she is
SGA. At 6 hours of age, Priscilla calls you and explains her baby seems to be
struggling to breathe. She wants to know if this is normal. When you assess the
newborn, you find a respiratory rate of 70 breaths/min and mild subcostal retractions.
1. What possible risk factors should you look for in Baby Angelini?
2. What is the most likely explanation for Baby Angelini’s respiratory rate and the
subcostal retractions? What priority nursing intervention should you initiate?
What should you tell Priscilla about the situation?
3. Does Priscilla’s infection put Baby Angelini at risk? What nursing interventions
should be in the newborn’s care plan to prevent infection and what signs and
symptoms of infection should you look for in the newborn?

RELATED RESOURCES
Explore these additional resources to enhance learning for this chapter:
• Student resources on thePoint, including answers to the What If . . . and Critical
Thinking Care Study questions, http://thepoint.lww.com/Flagg8e
• Adaptive learning powered by PrepU, http://thepoint.lww.com/prepu

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