NURSING CARE OF THE

HIGH-RISK NEWBORN TO
MATURITY
•ALTERED GESTATIONAL AGE

•ALTERED BIRTH WEIGHT

 ALTERED GESTATIONAL AGE
• TERM INFANTS – INFANTS BORN AFTER 38 WEEK
AND BEFORE 42 WEEK OF PREGNANCY.
• PRETERM INFANTS- INFANTS BORN BEFORE 37
WEEK
• POST TERM INFANTS- INFANTS BORN AFTER
43 WEEKS.
 ALTERED BIRTH WEIGHT
• APPROPRIATE FOR GESTATIONAL AGE(AGA)-
Infants who fall between the 10th and 90th
percentile of weight for their age regardless of
gestational age.
• SMALL FOR GESTATIONAL AGE(SGA)-
Infants who fall below the 10th percentile of
weight for their age.
•LARGE FOR GESTATIONAL AGE
(LGA)-
Infants who fall above the
90th percentile of weight for their
age.
•LOW BIRTH WEIGHT(LBW)- Infants
weighing less 2,500 g
•VERY LOW BIRTH WEIGHT(VLBW)-
Infants weighing 1,000 to 1,500 g

•EXTREMELY VERY LOW BIRTH

WEIGHT(EVLBW)- Infants born
weighing 500 to 1,000 g
DIFFERENCE BETWEEN SGA AND
PRETERM INFANTS
SGA PRETERM

• 24-44 weeks • Before 37 weeks

• Under 10th percentile of weight
• Strong possibility of congenital
malformations
• Pulmonary
problems-meconium
aspiration, pulmonary
hemorrhage
• Intracranial hemorrhage-
strong possibility
• Weight gain-very rapid
• Normal for age
• There’s a possibility of
congenital malformations
• Pulmonary problems-
Respiratory Distress
Syndrome(RDS)
• Intracranial hemorrhage-
possibility
• Weight gain-slow
PREMATURITY
•An infant born before 37 weeks
of gestation

•Weight of less than 2,500 at

birth
 CAUSES
•Low socioeconomic level
•Poor nutritional status
•Lack of prenatal care
• Multiple Pregnancy
•Previous early birth
•Race
•Cigarette smoking
•Age of the mother
•Order of pregnancy
•Closely spaced pregnancy
•Infections
•Obstetric complications
 APPEARANCE
•Small and underdeveloped
•The head is disproportionately large
•The skin is generally ruddy
•Covered with vernix caseosa
•Few or no creases on the soles of the
feet
•Unstable temperature
•Low resistance to infection
•Excessive lanugo
•Inadequate Surfactant
COMPLICATIONS
TO PREMATURITY
•Anemia
•Kernicterus
•Persistent Patent Ductus Arteriosus
•Periventricular/ Intraventricular
Hemmorhage
•RDS (Respiratory Distress
Syndrome)/ HMD(Hyaline Membrane
Disease)
•Retinopathy of Prematurity/
Retrolental Fibroplasia
•Necrotizing Enterocolitis
 PROBLEMS OF THE PRETERM
INFANTS
• Respiratory Problems
• Problems with maintaining body temperature
• Problems with maintaining adequate Nutrition
• Problems with CNS function
• Problems with decreased resistance to infection
• Problems with immature renal function
RESPIRATORY PROBLEMS DUE TO:
•Decreased number of functional alveoli
•Deficient surfactant level
•Smaller lumen in respiratory system
•Greater collapsibility of obstruction of the respiratory
passages.
•Insufficient calcification of the bony thorax
•Weak or absent gag reflex
•Immature and friable capillaries of the lungs.
 NURSING INTERVENTION
•Gently stimulate respiration. Gently rub the
back.
• Ensure patent airway. Suction as needed.
Proper positioning:
•Elevate head with neck slightly at 10
degrees
•Turn side to side every 2 hours
•Do not place in prone position
 NURSING INTERVENTION
•Monitor oxygen administration
•Avoid high concentrations of
oxygen to prevent
retrolental fibroplasias.
•Monitor pulse oximeter
 PROBLEMS WITH MAINTAINING
BODY TEMPERATURE
Unstable temperature due to:
•More heat loss due to larger body
surface area
•Limited amount of subcutaneous
fat.
•Limited brown fat
•Immature hypothalamus
•Friable capillaries
•Inadequate shiver response
•Inadequate muscle mass activity
 PROBLEMS WITH MAINTAINING ADEQUATE
NUTRITION DUE TO:
•Weak or absent suck, swallow and
gag reflex.
•Small stomach capacity.
•Weak abdominal muscles.
•Limited stores of nutrients
•Decreased ability to digest
proteins and absorb nutrients.
•Immature enzyme systems.
 IMPLICATION
•Caloric Intake is 200/220 kcal/kg of body weight.
•Sterile water for initial feeding to test ability to
suck, gag and swallow.
•Bottle feed for 20 minutes. Gavage the remainder
of the formula to avoid excessive fatigue.
•Be prepared to provide
nourishment other than oral
route such as TPN ( Total
parenteral Nutrition)
 TPN
a. To insert- position infant on back or toward the
right side with head and chest slightly elevated.
b.Measure correct length of catheter to be
inserted- from the tip of the nose to the earlobe to
the tip of the sternum.
c.Lubricate catheter with sterile water and insert
slowly into the mouth, esophagus and
stomach.
d .Initially check correct placement by x-ray
e.Subsequent check correct placement by aspirating 1 to
5 cc gastric contents.
f.Before starting the next feeding, aspirate residual from
the stomach, measure and return. Subtract residual to
the amount of the next feeding to avoid excessive feeding.
g.Burp after feeding by turning head or positioning infant
on the right side.
 SIGNS THAT PRETERM INFANT IS
READY FOR NIPPLE FEEDINGS
•Coordinated sucking, swallowing and breathing.
•Adequate gag reflex-usually at 34-36 weeks.
•Steady weight gain.
•Respiratory function that allows unlabored
sucking(less than 60 respirations per minute with
oxygen at 30 to 40%.
 PROBLEMS WITH CNS FUNCTION
DUE TO:
•Birth trauma with damage to immature structures.
•Bleeding from fragile capillaries.
•Impaired coagulation process- including
prolonged prothrombin time
•Recurrent anoxic episodes
•Predisposition to hypoglycemia.
 PROBLEMS WITH DECREASED
RESISTANCE TO INFECTION DUE TO:
•Shortage of stored maternal immunoglobulins- low levels
of IgG, may not receive IgA and IgM because of NPO-
elevated levels of IgA and IgM indicates infection in utero.
•Impaired ability to make antibodies
•Thin skin which is more sensitive and easily absorbs
medication
PROBLEM WITH IMMATURE RENAL
FUNCTION
•Unable to excrete all metabolites and
drugs.
•Unable to concentrate urine.
•Unable to maintain acid-base
balance
 PROBLEM WITH MAINTAINING
HEMATOLOGIC STATUS
•Increased capillary friability.
•Increased tendency to bleed (low prothrombin
levels)
•Slowed development of RBC
• Increased hemolysis
• Loss of blood from frequent laboratory tests.
POSTMATURITY
•Post-term or post-mature infant is an
infant born after 42 weeks of gestation.

•The problems of post term infants are

associated with the progressively less
efficient capacity of the placenta to
sustain intrauterine life.
 SIGNS AND SYMPTOMS:
•Absent vernix and lanugo
•Abundant scalp hair
•Dry, cracked and parchment like skin
•Little subcutaneous fat
•Yellow to green skin, nails and cord from
meconium staining.
•Old man wrinkled appearance
•Hard nails extending beyond fingertips.
 COMPLICATIONS:
•Hypoxia
•Perinatal Asphyxia
•Meconium Aspiration
•Hypoglycemia
•Polycythemia Vera-hypoxia causes increased production
of red blood cells. Management is partial exchange
transfusion.
•Thermal Regulation Problems- Cold stress. Management
is warm blanket, drop light or isollette.
 LONG TERM PROBLEMS:

•Poor weight gain

•Low IQ
 NURSING INTERVENTION
•Provide parental teaching about
newborn condition
•Monitor infant’s condition and provide
intervention specific to infant’s
needs.
•Prevent complications.
PROBLEMS RELATED
TO GESTATIONAL
WEIGHT
SMALL FOR GESTATIONAL AGE
•If the birth weight is below the 10th percentile on the
intrauterine growth curve for that age.

•May be born preterm (before 38 weeks)

•They may have experienced Intrauterine Growth

Restrictions (IUGR) or failed to grow at the expected
rate in utero.
 CAUSES
•Lack of adequate nutrition
•Age of mother
•Placental Anomaly
•Placenta did not obtain sufficient nutrients from the
uterine arteries
•Was inefficient at transporting nutrients to the fetus
•Placental damage- partial separation of the placenta
with bleeding
•Infections- Rubella, Toxoplasmosis
•Chromosomal abnormality- Down’s
syndrome
•Maternal conditions- malnutrition,
PIH(Pregnancy-Induced HPN), DM,
smoking, grand multiparity, alcoholism
 PHYSICAL CHARACTERISTICS AT
BIRTH

•Birth weight below 10th

percentile
•Reduced subcutaneous fat
•Loose dry skin
•Sunken abdomen
•Sparse hair growth
•Wide skull sutures
•Decreased muscle mass
•Less than normal chest and head
circumference
PROBLEMS ASSOCIATED WITH SGA
INFANTS
•Asphyxia Neonatorum
•Meconium Aspiration
•Hypoglycemia
•Hypothermia
•Hypocalcemia
•Polycythemia
•Congenital Anomalies
•Aspiration Syndrome
•Increased risk to infection
 LARGE FOR GESTATIONAL AGE
•Birth weight above 90th percentile
for age
• over 4000 grams or 9 lbs at term.
•MACROSOMIA- another term for LGA
infants
 CAUSES
•Maternal DM
•Multiparity
•Excessive maternal weight gain or obesity
•Transposition of the great vessel
•Beckwith Syndrome
•Congenital Anomalies- omphalocele
 DIAGNOSTIC/ASSESSMENT TESTS
During Pregnancy:
•Sonogram
•Nonstress Test- to assess placenta’s ability to sustain
the large fetus during labor
• Amniocentesis- to assess lung maturity
During Labor:
•Cephalopelvic Disproportion (CPD)
•Shoulder Dystocia
 IMPORTANT ASSESSMENT
CRITERIA FOR LGA INFANT
•Skin Color- jaundice, erythema
•Motion of extremities
•Asymmetry of anterior chest
•Eyes- for unresponsive or dilated pupils
•Seizure activities
 APPEARANCE
•May show immature reflexes
•May have extensive bruising or birth injury-
•broken clavicle or Erb”s Duchenne
Paralysis
•Caput succedaneum
•Cephalhematoma
PROBLEMS ASSOCIATED WITH LGA

•Hypoglycemia
•Hypocalcemia
•Hyperbilirubinemia
•Respiratory diseases
ACUTE CONDITIONS
OF THE NEONATE
RESPIRATORY DISTRESS
SYNDROME(RDS) OR
HYALINE MEMBRANE
DISEASE (HMD)
 RDS
•is a serious lung disorder
characterized by insufficient
surfactant that causes the alveoli
to collapse on expiration that
greatly increases the work of
breathing.
•Premature infants are those at highest
risk for RDS.
•RDS is more common in male infants
than female.
•It is the most common cause of death
among
premature infants.
 IMPORTANT SURFACTANTS THAT
MUST BE PRESENT AT BIRTH
•Lecithin/ Sphingomyelin- 2:1
•Phosphatidylcholine
•Phosphatidylglycerol
 CAUSES
•Prematurity
• Maternal Diabetes
Mgt: includes oxygen in high humidity and
changing infant’s position frequently.
•Meconium Aspiration Syndrome (MAS)
Mgt: oxygen administration, postural
drainage, antibiotic therapy
•Pneumonia
•CNS depression
•Tracheoesophageal atresia
•Asphyxia
•Transient Tachypnea
 SIGNS AND SYMPTOMS: USUALLY
BEGINS 2 HOURS AFTER BIRTH
•Low body temperature
•Flaring nostrils
•Tachypnea
•Sternal and subcostal
retractions
•Generalized cyanosis
•Grunting on expiration
•Pallor
•Heart Failure
•Periods of Apnea
•Bradycardia
Pneumothorax
Decrease breath sounds on
auscultation
Hypotension and shock
 DIAGNOSTIC TESTS
•Chest x-ray
•Blood gas analysis-
respiratory
acidosis
•Cultures of blood
 THERAPEUTIC MANAGEMENT
• Surfactant Replacement
• Oxygen Administration
• Ventilation
• Additional Therapy
a. Administration of muscle relaxant( Pavulon)
b. Administration of nitric oxide
• Infants with RDS must be kept warm
• Provide hydration and nutrition- IVF or gavage
feeding
 PREVENTION

•Sonogram
•Tocolytic agents
•Steroids
 SUDDEN INFANT
DEATH SYNDROME
(SIDS)
 SIDS
•Is the sudden death of a previously healthy infant.
•It is the most common cause of death between
ages 1 month to 1 year.
•The incidence of SIDS has declined dramatically
by more than 40% since 1992, which is attributed
to the initiative to put babies on their back,
called “BACK TO SLEEP CAMPAIGN”
 INFANT RISK FACTORS
•Prematurity
•Low Birth weight
•Twin or triplet
•Male gender
•Race (native Americans and
African-Americans are at highest
risk)
•Passive smoke exposure
•History of respiratory
compromise
•History of sibling who died of
SIDS
 MATERNAL RISK FACTORS
•Maternal age under 20
•Smoking or illicit drug use
•Anemia
•Multiple pregnancies with short
intervals
•Low socioeconomic status
•Poor prenatal care and limited
weight
•Current theories focus on neurologic
immaturity related to the infant’s inability to
sense and regulate oxygenation status
that leads to respiratory arrest. The infant
dies during sleep without noise or
struggle.
• Findings reveal
a. pulmonary edema
b. intrathoracic petechiae
c. chronic hypoxia.
 PREVENTIVE MEASURES
• Putting the infant on his back to sleep.
• No smoking anywhere near the infant.
• Removing pillows, quilts, stuffed toys and other soft surfaces
that may trap exhaled air from the infant’s crib or sleeping
environment.
• Using a firm mattress with snug fitting sheets.
• Make sure the infant’s head remain uncovered
while sleeping.
• Keeping the infant warm while sleeping but not
overheated.
THANK YOU!!