NURSING CARE OF HIGH RISK NEWBORN
 Age of the mother (teenagers)
HIGH RISK NEWBORN
- a newborn, regardless of gestational age or birth
weight, who has a greater than average chance of
morbidity or mortality because of conditions or
circumstances superimposed on the normal course
of events associated with birth and the adjustment
to extra uterine existence.
 Greater chance of complications because
of factors affecting :
• Fetal development
• Antenatal period of mother
• Labor and birth
 Complications - unexpected and without
warning.
 Certain risk factors make problems more
likely to occur
PRETERM NEWBORN
- a neonate born before 37 weeks of gestation
- with a birth weight of less than 2,500 g (5 lbs 8 oz)
- the primary concern relates to immaturity of all
body systems
APPEARANCE:
 Appears small and underdeveloped.
 Head is disproportionately large
(3 cm or more greater than chest size)
 Skin is generally unusually ruddy because the
infant has little subcutaneous brown fat beneath
it.
 Veins are easily noticeable and a high degree of
acrocyanosis may be present.
 Vernix is absent.
 Lanugo is usually extensive, covering the back,
forearms, forehead, and sides of the face.
 Both anterior and posterior fontanels are small
 Few or no creases on the soles of the feet.
 Most eyes of preterms are small.
 Cartilage of the ear is immature and allows the
pinna to fall forward and appears large in relation
to the head.
CAUSES OF PRETERM BIRTH:
 Low economic level
 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
 Order of birth (first and beyond the fourth)
 Closely spaced pregnancies
 Abnormalities of the mother’s reproductive
system, such as intrauterine septum
 Infections like UTI
 Obstetric complications, such as premature
rupture of membranes or premature
separation of the placenta
 Early induction of labor
 Elective caesarean birth
CLINICAL FINDINGS:
 Respirations are irregular with periods of apnea
 Body temperature is below normal
 Poor suck and swallow reflexes
 Diminished bowel sounds
 Increased/decreased urine output
 Extremities are thin w/ minimal creasing on soles
and palms
 Extends extremities & does not maintain flexion
 Lanugo present in wooly patches
 Skin thin, with visible blood vessels &
 Minimal subcutaneous fat pads
 Skin may appear jaundiced
 Testes undescended in boys
 Labia narrow in girls
NURSING DIAGNOSES:
Impaired gas exchange related to immature
pulmonary functioning
Risk for deficient fluid volume related to
insensible water loss at birth and small
stomach capacity
Risk for imbalanced nutrition, less than body
requirements related to additional nutrients
needed for maintenance of rapid growth,
possible sucking difficulty, and small stomach
Ineffective thermoregulation related to
immaturity
Risk for infection related to immature immune
defenses
Risk for impaired parenting related to
interference with parent-infant attachment
resulting from hospitalization of infant at birth
Deficient diversional activity (lack of
stimulation) related to preterm infant’s rest
needs
Risk for disorganized infant behavior related
to prematurity and environmental
overstimulation
Parental health seeking behavior related to
preterm infant’s needs for health
maintenance
  skull sutures may be widely separated from lack of
POST TERM NEWBORN normal bone growth
- a neonate born after 42 weeks of gestation  hair is dull and lustreless
 abdomen may be sunken
CLINICAL FINDINGS:  cord often appears dry and may be stained yellow
 Hypoglycemia  may have better neurologic responses
 parchment-like skin (dry & cracked) w/o lanugo  sole creases
 fingernails long & extended over ends of fingers  ear cartilage than expected for a baby of that
 profuse scalp hair weight
 body is long & thin
 extremities show wasting of fat & muscle LABORATORY FINDINGS:
 Meconium-staining may be present on nails &  poor placental function result from a biophysical
umbilical cord profile or non-stress test
 high hematoctrit levels
NURSING INTERVENTIONS  increase in the total number of red blood cells
 Provide normal newborn care.  Decreased blood glucose or a level below 40
 Monitor for hypoglycemia. mg/dL
 Maintain newborn’s temperature.
 Monitor I&O and electrolyte balance CLINICAL FINDINGS:
 Monitor for meconium aspiration.  fetal distress
SMALL FOR GESTATIONAL AGE (SGA)  lowered or elevated body temperature
- a neonate who is placed at or below the 10 th  Hypoglycemia
percentile on the intrauterine growth curve (IUGR)  signs of polycythemia
for that age.  ruddy appearance
- have experienced intrauterine growth restriction  Cyanosis
(IUGR) or failed to grow at the expected rate in  Jaundice
utero.  signs of infection
- may be born:  signs of aspiration of meconium aspiration
Preterm - before 38 weeks of gestation
Term - between 38 and 42 weeks NURSING DIAGNOSES:
Post term - past 42 weeks Ineffective Breathing Pattern related to
underdeveloped body systems at birth
CAUSES OF SGA: Risk for impaired thermoregulation related to lack
 Lack of adequate nutrition during pregnancy of subcutaneous fat
 Placental anomaly (either the placenta did not Risk for impaired parenting related to child’s high-
obtain sufficient nutrients from the uterine arteries risk status and possible congenital or neurologic
or it was inefficient at transporting nutrients to the impairment from lack of nutrients in utero
fetus)
 Placental damage (e.g. Partial placental NURSING INTERVENTIONS:
separation) 1. Maintain patent airway.
 Women with systemic diseases (decreases blood 2. Maintain body temperature.
flow to the placenta) 3. Observe for signs of respiratory distress.
 Mothers who smoke heavily or use narcotics 4. Monitor for infection and initiate measures to
prevent sepsis.
ASSESMENT FINDINGS: 5. Monitor for blood glucose levels & monitor for
 fundal height during pregnancy becomes signs of hypoglycemia.
 progressively less than expected 6. Initiate feeding and monitor for signs of aspiration.
 below average in weight, height and head 7. Provide stimulation such as touching & cuddling.
circumference
 wasted appearance
 may have small liver
 poor skin turgor
 generally appear to be of large head LARGE FOR GESTATIONAL AGE
- an infant who is above 90th percentile on an
- intrauterine growth for that gestational age
- also termed Macrosomia
- baby appears deceptively healthy at birth because of the
weight but a gestational age examination will reveal
immature development.
CAUSES OF LGA:
 mothers with diabetes mellitus
 multiparous women
 Beckwith syndrome (a rare condition characterized
by overgrowth)
 congenital anomalies (transposition of great
vessels)
ASSESSMENT FINDINGS:
 mothers uterus is unusually large for the date of
pregnancy
 baby cannot descend through the pelvic rim
during labor
 infant may show immature reflexes and low
scores on gestational age examinations in relation
to his or her size
 may have extensive bruising or a birth injury such
as broken clavicle or Erb-Duchenne paralysis from
trauma to the cervical nerves if born vaginally
 caput succedaneum, cephalhemotoma or molding
because of the large head
NURSING DIAGNOSES:
Ineffective Breathing Pattern related to possible
birth trauma in large-for gestational-age newborn
Risk for imbalanced nutrition, less than body
requirements related to additional nutrients
needed to maintain weight and prevent
hypoglycemia
Risk for impaired parenting related to high-risk
status of large-for-gestational age newborn
NURSING INTERVENTIONS:
1. Monitor v/s
2. Monitor blood glucose levels and for signs of
hypoglycemia.
3. Initiate early feedings.
4. Monitor for infection and initiate measures to
prevent sepsis.
5. Initiate feeding and monitor for signs of aspiration.
6. Provide stimulation such as touching & cuddling.
RESPIRATORY DISTRESS SYNDROME (RDS)
- a serious lung disorder caused by immaturity and
inability to produce surfactant resulting in hypoxia &
acidosis
- symptoms found most exclusively in the preterm
infant
- also known as Hyaline Membrane Disease (HMD)
- when premature labor cannot be arrested,
Betamethasone may be administered to enhance
surfactant
- additional factors are: hypoxia, hypothermia &
acidosis
SEQUELA OF RDS:
 HYPERBILIRUBINEMIA
 RETROLENTAL FIBROPLASIA
 BRONCHOPULMONARY DYSPLASIA (BPD)
- damage to alveolar epithelium of the lungs related
to high O2 concentrations and positive ventilation.
- may be difficult to wean infant from ventilator, but
most recover & have normal x-rays at 6 months to 2
years.
 NECROTIZING ENTEROCOLITIS
CLINICAL FINDINGS:
 Tachypnea (RR > 60 bpm) & increased
apical pulse
 Flaring nares & expiratory grunting
 Retractions & chin lag
 Decreased activity level & elevated
CO2 level in ABG
 Metabolic acidosis
 Decreased breath sounds
 Apnea
 Pallor & cyanosis
 Hypothermia & Poor muscle tone
 X-rays show atelectasis & high density in alveoli
 Monitor for color, RR, and degree of effort in
breathing.
 Support respirations as prescribed.
 Monitor ABG and O2 sat. levels q2-4H.
 Monitor ABG so that O2 administered is at the
lowest possible concentration to maintain
adequate arterial oxygenation. (less than 40%
concentration if possible)
 Schedule any premature newborn who required O2
support for an eye examination before discharge
to assess retinal damage.
NURSING INTERVENTIONS:
1. Suction q2H or more often as necessary.
2. Suction less than 5 sec. using sterile catheter
3. Position on side or back, with neck slightly hyper-
extended.
4. Prepare to administer surfactant replacement
therapy via E-tube
 5. Administer respiratory therapy (percussion & - generalized infection resulting from the presence of
vibration) as prescribed. bacteria in the blood.
6. Use padded cup or small O2 mask for percussion.
7. Use padded electric toothbrush for vibration CLINICAL FINDINGS:
8. Provide nutrition.  pallor
9. Maintain infant temp at 97.6 °F (36.2°C)  tachypnea
10. Support bonding.  tachycardia
11. Continuous positive air pressure (CPAP) or  poor feeding
POSITIVE END EXPIRATORY PRESSURE (PEEP) may  abdominal distention
be used.  temperature instability
12. Prepare parents for short- to long-term period of
O2 dependency if necessary. NURSING INTERVENTIONS
13. Encourage mother to pump breasts for future 1. Assess for periods of apnea or irregular respirations
breastfeeding if she so desires. 2. If apnea is present, stimulate by gently rubbing the
14. Encourage as much parental participation in chest or foot
newborn’s care as condition allows. 3. Administer oxygen as prescribed.
4. Monitor vital signs.
5. Maintain warmth in an isolette.
MECONIUM ASPIRATION SYNDROME 6. Provide isolation as necessary.
- aspiration of meconium either in utero or with the 7. Assess for fever.
first breath due to hypoxia resulting the vagal reflex 8. Monitor for I&O and obtain daily weight.
relaxation of the rectal sphincter, which releases 9. Monitor for diarrhea.
meconium into the amniotic fluid 10. Assess feeding & sucking reflex which may be
- occurs approx. in 10% to 12% of all pregnancies poor.
11. Assess for jaundice.
Meconium Aspiration Syndrome can cause respiratory 12. Assess for irritability and lethargy.
distress in three ways: 13. Administer antibiotics as prescribed and monitor
1. It causes inflammation of bronchioles because it is for toxicity.
a foreign substance.
2. It can block the small bronchioles by mechanical HYPERBILIRUBINEMIA
plugging. - the appearance of jaundice during the first 24
3. It can cause a decrease in surfactant production hours of life
through lung cell trauma. - also called PATHOLOGIC JAUNDICE
- occurs because of disorders of:
CLINICAL FINDINGS: Production, Hepatic Uptake, Conjugation and
 difficulty establishing respirations at birth Enterohepatic Circulation
 APGAR score opt to be low - evaluation is indicated if serum level is >12mg/dl in
 presence of tachypnea, retractions and cyanosis the term newborn
 apnea (a pause in respirations longer than 20 - therapy is aimed at preventing KERNICTERUS
seconds) could be present  Kernicterus - results in
permanent neurological damage
THERAPEUTIC MANAGEMENT: resulting from deposition of
1. Suction patient (naso/tacheal) bilirubin in the brain cells.
2. Administer oxygen and assist ventilation
3. Amniotransfusion can be used to dilute the amount  Physiologic Jaundice
of meconium in the amniotic fluid and reduce the
- a progressive rise in unconjugated bilirubin to
risk of aspiration
a peak of 5-6 mg/dL between 60 and 72 hours
4. Antibiotic therapy may be used (to prevent the
of life in white and African-American babies
development of Pneumonia as a secondary
and 10-14 mg/dL between 72-120 hours of
problem)
life in Asian babies.
- rapid decline in total serum bilirubin occurs by
the 5th or 7-10th day respectively.
SEPSIS
CAUSES:
  Rh incompatibility – if the mother’s blood is Rh (D) 9. Monitor for BRONZE BABY SYNDROME
negative and the fetal blood type is Rh positive - grayish brown discoloration of the skin
(contains the D antigen), the introduction of fetal 10. Reposition q2H.
blood 11. Provide stimulation.
 ABO Incompatibility 12. Monitor for signs of hyperbilirubinemia as
rebound hyperbilirubinemia occurs after therapy.
CLINICAL FINDINGS:
 Jaundice
 Elevated serum bilirubin levels
 Enlarged liver
 Poor muscle tone
 Lethargy
 Poor sucking reflex

NURSING INTERVENTIONS:
1. Monitor for presence of jaundice.
2. Examine the newborn’s skin color in natural light.
- press fingers over bony prominence or tip of
nose to press out capillary blood from the
tissues.
- jaundice starts from head, chest abdomen arms
& legs then hands and feet.
3. Keep newborn well hydrated to maintain bld
volume.
4. Facilitate early, frequent feeding.
- hasten passage of meconium and excretion of
bilirubin.
5. Report to physician any signs of jaundice in the
first 24 hours and any abnormal signs and
symptoms.
6. Prepare for phototherapy & monitor closely during
treatment.

PHOTOTHERAPY
- Use of intense florescent lights to reduce serum
bilirubin level in the newborn
- Injury from treatment such as eye damage,
dehydration, or sensory deprivation can occur.

NURSING INTERVENTIONS:
1. Expose newborn’s skin as much as possible.
2. Cover the genital area and monitor genital area
for skin irritation or breakdown.
3. Cover the eyes with eye shields or patches.
- make sure eyelids are closed when shields or
patches are applied.
4. Measure the quantity of light q8H
5. Monitor skin temp closely.
6. Increase fluids for compensate for water loss.
7. Expect loose green stools & green urine.
8. Monitor the skin color with florescent light turned
off q4-8H.