NCLEX-RN: Maternal–Newborn Nursing

Maternal–Newborn Nursing: NEWBORN

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: High-Risk Infants

Focus topic: Maternal–Newborn Nursing

Maternal–Newborn Nursing: Preterm (Premature) Newborn

Focus topic: Maternal–Newborn Nursing

Definition: An infant born before the end of the thirthyseven week regardless of birth weight.

Characteristics
A. Maternal factors: diabetes, PIH, chronic disease, chronic poor nutrition, premature rupture of membranes, placenta previa, abruptio placenta, incompetent cervix, other premature births, age, multiple gestation, smoking, drugs, infection, etc.
B. Fetal factors: congenital anomalies, infection, other diseases.
C. Socioeconomic factors: low socioeconomic status, poor nutrition, unmarried, under 27 years of age.
D. Other: cause unknown; accounts for large percentage of premature births.
E. Incidence: 12% of all live births and 15% in socioeconomically deprived populations.

  • Factors associated with pre-maturity make it the leading cause of death in neonates.
  • Primarily due to respiratory distress syndrome, infection, and intracranial hemorrhage.

Assessment
A. Assess digestive system.

  • Weak swallow/suck reflexes until about 33–34 weeks; poor gag/cough reflex increase risk of aspiration.
  • Suck and swallow reflexes uncoordinated.
  • Small stomach capacity.
  • Poor ability to tolerate fats.
  • Immature enzyme system.

B. Assess CNS and muscle tone.

  • Poor muscle tone: muscles appear limp; baby assumes froglike position when placed on abdomen.
  • Weak, feeble cry.
  • Weak or absent reflexes.
  • Heat regulation unstable.
    a. Body temperature below normal, small muscle mass, absent sweat or shiver responses.
    b. Large body surface in proportion to body weight.
    c. Lack of subcutaneous fat.
    d. Poor capillary response to environmental changes.
  • Susceptibility to brain damage from high levels of bilirubin (kernicterus).

C. Assess respiratory system.

  • Insufficient production of surfactant allows alveoli to collapse.
  • Immaturity of alveoli and/or decreased number of functioning alveoli.
  • Immaturity of musculature and rib cage contributes to increase work to expand alveoli.
  • Prone to respiratory disease.
  • Periodic breathing pattern—pauses < 15–20 seconds.

D. Assess integumentary system.

  • Skin thin and capillaries easily seen.
  • Little subcutaneous fat.
  • Lanugo prominent: hair on head is fine and fuzzy.
  • Vernix may cover body if born between 31 and 33 weeks.

E. Assess immune system: resistance to infection decreased.

  • Lack of passive immunity from mother (occurs in late pregnancy).
  • Inability to produce own antibodies—immature system.
  • Difficulty localizing infection due to decreased inflammatory response.
  • Skin is thin and offers little protection from disease-causing organisms.

F. Assess hepatic system: liver immature.

  • Poor glycogen stores—increased susceptibility to hypoglycemia.
  • Inability to conjugate bilirubin—susceptible to hyperbilirubinemia.
  • Decreased ability to produce clotting factors.
  • Decreased ability to produce immune factors.

G. Assess circulatory system.

  • Capillary fragility increases susceptibility to hemorrhage, especially intraventricular (ruptures easily leading to signs of increased intracranial pressure—hypotonia, lethargy, bulging fontanels, increasing occipitofrontal circumference [OFC], bradycardia, apnea, tremors, seizures).
  • Prone to anemia—poor iron stores.

H. Assess renal system.

  • Renal function immature—poor ability to concentrate urine.
  • Fluid and electrolyte balance precarious.
  • Easily dehydrated.
  • Increased time to eliminate drugs.
  • Implementation

A. Provide immediate care to infant.

  • Give immediate attention in delivery room and transport to nursery to maintain heat.
    a. Maintain skin temperature at 96.8 to 97.7°F (36 to 37°C) in Isolette or radiant heated crib.
    b. Warming infant too quickly may cause apneic spells.
    c. Gradually wean infant from heated environment and monitor temperature until stable, q 1–3 hours as indicated.
  • Administer humidity (distilled water) usually between 40 and 70% as ordered.

B. Evaluate respiratory status.

  • Check respiratory rate—every hour and prn.
  • Observe for the following signs of respiratory distress:
    a. Color of skin: circumoral pallor, pallor entire body, cyanosis (late).
    b. Flaring of nares.
    c. Expiratory grunting, retractions.
    d. Tachypnea
    e. See-saw movements.
    f. Diminished breath sounds.
  • Auscultate breath sounds with stethoscope.
  • Analyze oxygen concentration (transcutaneous oxygen monitor) every 1–2 hours or as necessary to prevent retrolental fibroplasia and to ensure adequate oxygenation.
  • Observe for periods of apnea and stimulate by gently rubbing chest or tapping foot.
  • Percuss, vibrate, and suction as ordered to remove mucus.

C. Reposition every 2 hours to promote aeration of all lobes of the lung and facilitate drainage.
D. Monitor blood gases and electrolytes frequently; IV regulated by infusion pump to prevent circulatory overload.

E. Initiate feedings—based upon ability to feed.

  • Reflexes
  • Use preemie nipple.
  • Monitor for abdominal distention, emesis, tolerating feedings.

F. Give gavage feeding if respirations are 60 breaths per minute or more. Infants often require alternate feedings of gavage and bottle feeding.
G. Maintain I&O, including stool, and weigh daily.
H. Organize care to conserve energy with rest periods after each feeding.
I. Monitor closely for early signs of necrotizing enterocolitis (NEC).

  • Often occurs as a result of intestinal ischemia, which may occur with asphyxia when the blood is shunted to the brain or heart.
  • Common symptoms include: abdominal distention, poor feeding, vomiting, blood in stools, temperature, redness.
  • Treatment includes NPO, IV, fluids, antibiotics, and surgery.

J. Monitor growth and development: Measure head circumference and length at least once a week; check weight daily and note changes and trends.
K. Maintain aseptic technique and strict isolation techniques with infected babies.
L. Prevent skin breakdown: Change position frequently; careful cleansing and handling techniques.
M. Observe for signs of infection: vomiting, jaundice, lack of appetite, and lethargy.
N. Check heart rate by apical pulse for a full minute every 1–2 hours.
O. Frequently check for bleeding from umbilical catheter.

  • Apply pressure to puncture site as necessary to prevent bleeding.
  • Administer vitamin K as ordered after birth to prevent hemorrhage.
  • Frequently check monitors if monitored electronically.

P. Gently stroke and talk to baby when giving care.
Q. Hang colorful mobiles or other nonharmful objects in crib for sensory stimulation.
R. Hold baby during feeding as soon as condition permits.
S. Encourage parents to hold, cuddle, feed, and diaper baby as soon as baby’s condition permits.
T. Provide for family’s needs.

  • Allow parents to visit baby frequently; as soon as possible, involve parents in infant care to promote parent-to-infant attachment.
  • Answer questions openly, provide up-to-date information on baby’s progress.
  • Allow parents to talk freely about infant, give support as needed, and help parents to accept reality of situation.
  • Explain specialized care to parents. After discharge, have them report to pediatrician any of the following symptoms: diarrhea, vomiting, lack of appetite, or elevated temperature.
  • Allow mother to feel confident in caring for infant before discharge. Explain to mother infant’s special needs.

Late Preterm Baby (Born at 34 to 37 Weeks)

Characteristics
A. Needs are similar to premature infants.

  • Infants formerly evaluated solely on weight.
  • Gestational age is a better tool to predict problems.

B. Appear as ordinary newborns, but at risk for

  • Respiratory problems.
  • Temperature instability.
  • Hyperbilirubinemia.
  • Hypoglycemia.
  • Infection.
  • Breastfeeding failure.

Assessment
A. Respiratory distress syndrome.

  • Disorder of immature lungs and deficiency of surfactant.
  • Symptoms may appear at birth or after a few hours.
    a. Respirations up to 120 without retractions.
    b. Tachypnea—thought to be related to delayed absorption of lung fluid.
    c. Cyanosis.
    d. Grunting.
    e. Retractions.

B. Hyperbilirubinemia (jaundice)—frequent in late preterm babies.

  • Immature liver mechanisms aggravated by dehydration and poor feeding.
  • Delays clearing of bilirubin in bowel.
  • Phototherapy is treatment in hospital or home.

C. Infections.

  • May be acquired before birth, during delivery, or in neonatal period (group B Streptococcus).
  • Signs and symptoms often nonspecific (e.g., respiratory problems, hypothermia, lethargic).
  • Diagnosis may be by blood cultures, CBC, and screening.

D. Hypoglycemia—blood glucose level may fall after birth.

E. Hypothermia—prone to this condition because of large surface area in relation to body weight.
F. Dehydration resulting from poor feeding ability, compounded by phototherapy.

Implementation
A. Constant observation for preterm babies.

  • May require O2, vital signs, and pulse oximetry.
  • Nutrition via nasogastric (NG) tube.
  • IV therapy to prevent dehydration.

B. Preterm infants may have feeding problems—dehydration.

  • Preterm babies being breastfed may have problems latching, sucking, and swallowing.
  • May require supplemental bottle formula or expressed breast milk via NG tube.

C. Late development of cerebral cortex (increases 50% between 34 and 40 weeks’ gestation).

  • Avoid stimulation, light, sound.
  • Avoid painful actions.

D. Hypothermia.

  • Defer bathing and use radiant warmer.
  • Skin-to-skin contact with mother.

Maternal–Newborn Nursing: Respiratory Distress Syndrome

Focus topic: Maternal–Newborn Nursing

Definition: A group of clinical symptoms signifying that the infant is experiencing problems with the respiratory system—also called hyaline membrane disease.

Characteristics
A. Symptoms are the result of a decrease in the amount of surfactant in the infant’s lungs caused by one of the following conditions.

  • Prematurity: immaturity of lungs, decreased number of mature alveoli, and inability to produce surfactant.
  • Hypoxia and acidosis.
  • Hypothermia.
  • High concentration of oxygen.

B. Respiratory distress syndrome is the most common cause of death in infants.

C. Prevention of respiratory distress syndrome (RDS).

  • Evaluation of amniotic fluids to assess fetal lung capacity.
  • Administration of glucocorticoids (Celestone) to induce pulmonary maturation.
    a. Prenatal IM injections of 12 mg 1×/day for 2 days.
    b. Birth may be delayed 24 hours after first round of treatment.

Assessment
A. Assess for increased respirations: greater than 60/min.
B. Assess for retractions: sternal and intercostal.
C. Check for presence of cyanosis and expiratory grunting; assess for increased number and length of apnea episodes.
D. Assess for increased apical pulse.
E. Evaluate nasal flaring and chin lag.
F. Evaluate for lack of activity or movement.
G. Assess for inability to take in sufficient oxygen leading to low oxygen and hypoxemia.
H. Assess for hypercarbia due to elevated levels of carbon dioxide.
I. Check for respiratory acidosis due to retention of carbon dioxide as a result of inadequate pulmonary ventilation.
J. Evaluate for decreased body temperature.
K. Check for metabolic acidosis due to increased production of lactic acid and decreased pH.
L. Evaluate x-ray examination, which may reveal

  • Atelectasis: collapsed portions of lung.
  • Reticulogranular pattern bilaterally.
  • Air bronchograms.

Implementation
A. Prevent cold stress: Infant is usually placed in
Isolette or open crib with overhead radiant warmer. Skin temperature is maintained with probe at minimum 97.7°F (36°C)—thermoneutral environment.
B. Provide for nutrition and hydration: Usually give IV glucose fluids during acute periods, then gradually increase feedings as tolerated.
C. Do careful monitoring of blood gases and electrolytes, color, and activity.
D. Administer oxygen for hypoxemia.

  • Maintain paO2 at 50–70 mm Hg warmed and humidified; monitor and record.
  • Adjust O2 concentration based on arterial blood gases (ABGs) (usually 30–50% under an oxyhood).
  • Administer via hood, nasal prongs, endotracheal tubes, or bag and mask.
  • Oxygen may be given at atmosphere or increased airway pressure.
  • Apply continuous positive pressure to lungs during spontaneous breathing. Continuous positive airway pressure (CPAP) may be used for moderate cases.
  • Apply mechanical ventilatory assistance for severe cases.

E. Surfactant replacement therapy is available to decrease severity of RDS—given via endotracheal tube.
F. Supportive ventilation therapy to prevent hypoventilation and hypoxia.

  • Mild cases may require only increased O2.
  • Use of CPAP delivered via endotracheal tube may be required.
  • Increased urination (weigh diapers) signifies fluid moving out of lungs into bloodstream; kidney perfusion indicates baby’s condition is improving.
  • Monitor chest expansion and ventilator setting (if too high, pneumothorax may occur).

G. Gently handle infant with as little disturbance as possible.
H. Position in side-lying or supine position with neck slightly extended (sniffing position).
I. Keep parents informed of infant’s progress.
J. Allow parents to visit infant as much as possible and express their feelings about infant’s illness.
K. Gently stroke and talk with infant while giving care.

Maternal–Newborn Nursing

Maternal–Newborn Nursing: Small for Gestational Age

Focus topic: Maternal–Newborn Nursing

Definition: Refers to infants who are significantly under size vfor gestational age (below 10th percentile). Also called intrauterine growth retardation (IUGR).

Characteristics
A. Postmature infants.
B. Defective embryonic development.
C. Placental insufficiency.
D. Associated factors: diabetes, toxemia, maternal infection, maternal malnutrition, cigarette smoking, multiple gestation.
E. Infant appearance.

  • Little subcutaneous tissue.
  • Loose, dry, scaling skin.
  • Appears thin and wasted; old for size.
  • May be meconium staining of skin, nails.
  • Sparse hair on head.
  • Active, alert, seems hungry.
  • Cord dries more rapidly than normal infants.

Assessment
A. Assess for hypoglycemia or poor glucose control: nervousness, pallor, apnea, temperature instability, high-pitched, weak cry.
B. Assess for cold stress: lethargy, poor feeding pattern, cold to touch, respirations increased.
C. Assess for asphyxia: may have been deprived while in utero or aspirated amniotic fluid. Infant may require resuscitation at birth.
D. Assess for polycythemia: usually asymptomatic but may have tachycardia, tachypnea, respiratory distress.

Implementation
A. Provide care similar to premature infant until the infant is stabilized.
B. Protect from cold stress: Keep warm, usually in Isolette.
C. Perform tests for glucose levels.
D. Weigh daily and maintain I&O.

Maternal–Newborn Nursing: Postmature Infant

Focus topic: Maternal–Newborn Nursing

Definition: Refers to an infant of over 42 weeks’ gestation.

Characteristics
A. Placental function decreased.
B. Nutritional and oxygen needs are not met.
C. Infants exposed to chronic hypoxia.
D. Easily stressed during labor.
E. Increased morbidity and mortality due to above factors.
F. Increased incidence of labor dystocia due to large size of infant.

Assessment
A. Assess that vernix and lanugo are no longer present.
B. Assess skin: appears dry and wrinkled.
C. Check fingernails and toenails: usually long and may be meconium stained.
D. Assess size: may be small for gestational age (SGA) due to nutritional deficiency and chronic hypoxia.
E. Observe for hypoglycemia.
F. Observe for signs of birth injury: dislocated shoulder, fractured pelvis, facial paralysis, and CNS injury.

Implementation
A. Similar to care given to preterm infants if premature characteristics are observed.

  • Requires immediate attention in the delivery room.
  • Suctioning before infant’s first breath will prevent meconium aspiration.
  • Heated crib or Isolette to prevent cold stress.
  • Evaluate respiratory rate consistently and observe for signs of respiratory distress—administer oxygen and humidification if necessary.
  • Monitor blood gases, electrolytes, and blood sugar.
  • Give oral feedings or check need for IV feedings.
  • Maintain I&O records.
  • Observe for signs of infection; monitor administration of antibiotics.
  • Prevent skin breakdown.

B. Symptoms depend on condition at birth. Care for as SGA in those infants who are underweight for gestational age.
C. Monitor for possible complications (asphyxia neonatorum, polycythemia, birth injuries).

Maternal–Newborn Nursing: Hyperbilirubinemia

Focus topic: Maternal–Newborn Nursing

Definition: An abnormal elevation of bilirubin in the newborn resulting in yellow-tinged skin color. Clinical jaundice is seen with total bilirubin level of 5–6 mg/dL.

Characteristics
A. Functional immaturity of the liver: usually appears after 24 hours and disappears after 10 days; physiologic jaundice.
B. Bacterial infections.
C. ABO and Rh incompatibilities: usually show up in the first 24 hours and may be severe.
D. Enclosed bleeding, such as hematoma, from trauma of delivery.
E. Pregnanediol hormone, present in mother’s breast milk, may contribute to jaundice. (Hormone inhibits conjugation of bilirubin by glucuronyl transferase—occurs in fewer than 1% of breastfeeding mothers.)
F. May lead to kernicterus—a deposit of yellow pigmentation in basal ganglia of brain results in irreversible brain damage, caused by high levels of unconjugated, unbound bilirubin.

Assessment
A. Observe for jaundice, which progresses from head to extremities (color of sclera, mucosa, and blanched skin).

  • Physiologic jaundice occurs 3–5 days after birth (total bilirubin up to 12 mg/dL in fullterm infants and up to 15 mg/dL in preterm infants).
  • When levels rise within 24 hours of birth, are above 12–14 mg/dL in full-term infants and 15 mg/dL in premature infants, or persists beyond 7 days, jaundice may be termed pathological.

B. Observe for pallor.
C. Evaluate activity level: Infant may be lethargic and feed poorly.
D. Assess if urine is concentrated, or stools are light in color.
E. Assess progress of condition: if untreated, infant may progress from muscular rigidity or flaccidity to increased lethargy, high-pitched cry, respiratory distress, decreased Moro reflex, and spasms.
F. Evaluate blood tests.

  • Hemoglobin.
  • Bilirubin: Important to measure amount of indirect or unconjugated bilirubin in blood, since unbound bilirubin is free to deposit in body tissues, such as skin, cardiac muscle, brain, and kidney.
  • Unconjugated bilirubin crosses blood–brain barrier, and when deposited in the brain, can lead to kernicterus and brain damage.

G. Assess fluid balance.

Implementation
A. Observe infant for signs of increased jaundice.
B. Observe for and prevent acidosis/hypoxia and hypoglycemia, which decrease binding of bilirubin to albumin and contribute to jaundice.
C. Maintain adequate hydration and offer fluids between feedings as ordered.

  • Infant may be on increased fluids to aid in excretion of bilirubin.
  • Phototherapy can cause loose stools so there is a danger of dehydration.
  • When infant is NPO, the infusion rate may need to be increased.

D. Using skin temperature probe, maintain skin temperature at 97.6°F (36.4°C); avoid cold stress.
E. Prevent infection.
F. Provide phototherapy: phototherapy lamp breaks down bilirubin into water-soluble products.

  • Apply diaper cover over genital area. Do not clothe infant.
  • Cover infant’s eyes to prevent retinal damage.
  • Change baby’s position every 2 hours to ensure adequate exposure.
  • Remove infant from light and remove eye patches during feedings; dress to keep infant warm.
  • Carefully examine eyes for signs of irritation from eye patches.
  • Keep an accurate record of hours spent under bili-lights.

G. Meet infant’s emotional needs: cuddle, talk to infant, etc.
H. Reinforce physician’s teaching to parents and allow parents to express concerns and feelings.

I. Monitor exchange transfusion: considered when bilirubin reaches high levels (20–25 mg/dL in full-term infant; lower levels in premature infants). No “safe level” of bilirubin to prevent kernicterus— influenced by combination of bilirubin level, neurological age, and condition.

  • Exchange transfusion is usually performed in operating or delivery room.
  • Infant is usually placed in radiant warmer and restrained.
  • Resuscitative equipment and oxygen should be available.
  • Blood should be no more than 24 hours old and warmed.
  • Stomach contents are aspirated to prevent vomiting.
  • Baseline vital signs are obtained and checked every 15 to 30 minutes.
  • Transfusion is usually given via umbilical catheter.
  • Exchange usually done by alternately withdrawing and adding blood until about 80% of infant’s total blood volume has been exchanged—maximum 500 mL Rh-negative blood is given.
  • Exchange usually takes 45 to 60 minutes.

J. Administer care after transfusion.

  • Observe for bleeding from the umbilical cord.
  • Observe vital signs frequently.
  • Maintain warmth.
  • Administer oxygen if needed.
  • Observe for signs of hypoglycemia, sepsis, cardiac arrest, thrombocytopenia, or other irregularities.
  • Handle infant.
  • Resume feedings after 4 to 6 hours.
  • Keep umbilical cord moist in case other transfusions are indicated.

Maternal–Newborn Nursing: Hemolytic Disease (Erythroblastosis Fetalis)

Focus topic: Maternal–Newborn Nursing

Definition: The destruction of red blood cells that results from an antigen–antibody reaction and is characterized by hemolytic anemia or hyperbilirubinemia.

Characteristics
A. Rh incompatibility: Rh antigens from the baby’s blood enter the maternal bloodstream. The mother’s blood does not contain Rh factor, so she produces anti-Rh antibodies. These antibodies are harmless to the mother but attach to the erythrocytes in the fetus and cause hemolysis. Exchange of fetal and maternal blood takes place primarily when the placenta separates at birth.

  • Passive immunization or RhoGAM, Rho(D) immune globulin, should be given to the mother within 48 to 72 hours after delivery.
    a. Given if Rh-negative mother (approximately 15% of white population have Rhnegative factor) delivers Rh-positive fetus but remains unsensitized.
    b. Currently, the woman receives Rho(D) immune globulin at 28 weeks; it may also be given at 34 weeks’ gestation.
    c. Immunization protects mother and fetus.
  • Sensitization rare with first pregnancy.
  • Diagnosis of Rh incompatibility.
    a. Begins in pregnancy, with the discovery of antibodies in an Rh-negative mother’s blood by means of indirect Coombs’ test.
    b. Titration is used to determine the extent to which antibodies are present.
    c. Spectrophotometric analysis of amniotic fluid for bilirubin determines the severity of the disease—the higher the bilirubin content, the more severe the disease.
    d. Testing of cord blood—direct Coombs’ test—determines the presence of maternal antibodies attached to baby’s cells.

B. ABO incompatibility—usually less severe.

Assessment
A. Assess for anemia that is caused by destruction of red blood cells. Severe anemia usually accompanied by cardiac decompensation, edema, ascites, hypoxia, and may result in death.
B. Assess for jaundice, which develops rapidly after birth—before 24 hours.
C. Evaluate for edema—usually seen in stillborn infants or those who die shortly after birth; most likely due to cardiac failure.

Implementation
A. Administer immunization to the mother against hemolytic disease with RhoGAM as ordered. (Now given at 28 weeks and postpartum.)
B. Monitor exchange transfusion after birth or intrauterine transfusion. Use Rh-negative blood.
C. Follow interventions listed under hyperbilirubinemia.

Maternal–Newborn Nursing: Sepsis in the Neonate

Focus topic: Maternal–Newborn Nursing

Definition: Generalized infection resulting from the presence of pathogenic bacteria in the bloodstream—mortality may reach 50% when condition appears shortly after birth. May be caused by immature immune system—decreased ability to localize and fight infection.

Predisposing Factors
A. Prolonged rupture of membranes, over 24 hours.
B. Long, difficult labor or prolonged resuscitation after birth.

C. Maternal infection.
D. Aspiration of amniotic fluids or vaginal secretions during birth.
E. Aspiration of formula after birth.
F. Infection within nursery or among nursery personnel (nosocomial).
G. Usually appears within the first 48 hours after birth but may begin prenatally or postdelivery.
H. May quickly lead to septicemia or meningitis if not treated promptly.
I. Beta-hemolytic strep vaginosis most common cause; need to culture antepartally.

Assessment
A. General assessment is important as symptoms may
be vague and subtle.
B. Assess for periods of apnea or irregular respirations.
C. Assess for low-grade or subnormal temperature—fever rare (temperature instability).
D. Assess feeding, which may be poor, and sucking reflex.
E. Evaluate activity level for lethargy.
F. Check for presence of diarrhea.
G. Check for jaundice.
H. Assess for irritability, seizure activity.
I. Diagnosis is made from cultures taken of blood, urine, spinal fluids, throat, skin lesions, and the umbilical area or aspiration of gastric contents, which are examined for polymorphonuclear cells.
J. Assess for results of cervical culture when admitted into labor.

Implementation
A. Administer antibiotics if appropriate and observe carefully for toxicity because of liver and kidney immaturity—viral cause is treated symptomatically except herpes simplex and respiratory syncytial virus (RSV).
B. Maintain warmth—usually in an Isolette.
C. Administer oxygen as necessary.
D. Administer IV fluids if ordered; otherwise, give fluids as ordered to maintain hydration, electrolytes, and calories.
E. Maintain Standard Precautions and proper hand hygiene techniques.
F. Check respiratory rate and apical pulse frequently.
G. Stimulate if apnea is present by gently rubbing chest or foot.
H. Maintain intake and output.
I. Check temperature.
J. Weigh daily.
K. Observe for signs of jaundice.
L. Keep parents informed of infant’s progress.
M. Allow parents to visit infant as much as possible.
N. Talk and gently stroke infant while giving care.

Maternal–Newborn Nursing: Infants of Diabetic Mothers

Focus topic: Maternal–Newborn Nursing

Definition: Infants with blood glucose level of less than 40 mg/dL. Most have been exposed to elevated maternal glucose levels in utero.

Characteristics
A. May be delivered early to prevent intrauterine death; usually delivered after 36 weeks.
B. Often delivered by cesarean section.
C. Children with diabetic mothers have a higher incidence of congenital abnormalities than the general population.
D. High incidence of hypoglycemia, respiratory distress, hypocalcemia, and hyperbilirubinemia.

Assessment
A. Assess for excessive size and weight due to excess fat and glycogen in tissues.

  • High blood sugar levels in mother cross the placenta and enter the baby’s bloodstream, elevating blood sugar levels.
  • High blood sugar stimulates infant’s metabolic system to store glycogen and fat and increase the production of insulin (even though maternal blood sugar supply is lost).
  • High levels of insulin deplete glucose levels, which leads to hypoglycemia (occurs 1–3 hours after birth).

B. Assess infant: birth trauma, large for gestational age (LGA), may have puffy face and cheeks, increased risk for congenital defects (cardiac, spine).
C. Observe for signs of hypoglycemia—difficulty feeding, lethargy, apnea, subnormal temperature, tremors, jitteriness, seizures, cyanosis, high-pitched cry.
D. Observe for hypocalcemia (may be caused by prematurity or stress); tremors.
E. Observe for signs of respiratory distress—tachypnea, cyanosis, retractions, grunting, nasal flaring.
F. Hyperbilirubinemia.

Implementation
A. Administer care similar to premature infant.
B. Caloric intake important—early feeding major preventive approach.

  • Breast or formula feeding started.
  • Formula (oral glucose source) given after plasma glucose reading < 40.
  • Infant may need IV therapy depending on condition—5% to 10% glucose, the highest safe concentration.
  • Concentrations of 25% to 50% dextrose contraindicated because rebound hypoglycemia could occur.

C. Be aware that any infant of a diabetic mother will be started on hypoglycemia protocol regardless of weight.

D. Monitor blood glucose frequently according to orders (usually by 30 min, q 1, 2, 4, 6, 9, 12, and 24 hours after birth).

Maternal–Newborn Nursing: Hypoglycemia

Focus topic: Maternal–Newborn Nursing

Definition: Abnormally low level of sugar in the blood (blood glucose value of 40 mg/dL).

Characteristics
A. Placental dysfunction.
B. Diabetes in mother.
C. Cold stress.
D. Renal disease, cardiac disease, preeclampsia, or chronic infection in the mother.
E. Small for gestational age (SGA) infants.
F. Postterm infant.
G. Asphyxia at birth.
H. Infection in infant or any condition that stresses the metabolic rate and increases the need for glucose.

Assessment
A. Assess for presence of cyanosis.
B. Assess for increased respiratory rate.
C. Check any jitteriness, twitching, nervousness, or tremors.
D. Evaluate for lethargy and poor muscle tone.
E. Assess unstable temperature.
F. Assess for shrill or intermittent cry.
G. Check for any feeding problems.
H. Evaluate apneic periods closely.
I. Evaluate blood sugar values: normal is 40 to 100 mg/dL; usually around 60 to 75 mg/dL.

  • Term infant: below 40 mg/dL.
  • Preterm: below 50 mg/dL.

J. Monitor screening that is done with heel stick testing, with laboratory studies as a follow-up.

Implementation
A. Prevent low blood glucose through early feedings (immediate breastfeeding or formula, D5W, or D10W may still be used in some hospitals).
B. Administer glucose orally or IV, depending on baby’s condition—IV started with 10% glucose, highest safe concentration.
C. Perform close monitoring of blood sugar values every 1–2 hours.
D. Give care as for other high-risk infants.

Maternal–Newborn Nursing: Newborn Infected with Group B Streptococcus

Focus topic: Maternal–Newborn Nursing

Characteristics
A. Newborn infected with group B Streptococcus (GBS) manifests severe, invasive disease.
B. Risk factors.

  • Prematurity (< 37 weeks).
  • Membranes ruptured more than 12 hours.
  • Intrapartum temperature > 100.4°F (38°C).
  • Previously infected infant.
  • GBS bacteriuria identified during pregnancy.

Assessment
A. Assessment critical to survival—infant may deteriorate rapidly in first 12–24 hours if infection present.
B. Early onset—symptoms appear within hours or 1 week.

  • Signs of respiratory distress or aspiration pneumonia.
    a. Grunting, cyanosis.
    b. Apnea.
    c. Temperature instability.
    d. “Shocky” appearance (cyanosis, pallor, clamminess).
  • X-ray to identify pneumonia.

Implementation
A. Clinical therapy is based on detection of carriers and preventive treatment with prophylactic antibiotics for the mother.
B. Newborns with GBS infection are treated as sepsis neonatorum.
C. Two blood cultures are obtained from two peripheral sites.
D. Antibiotics instituted STAT, then altered according to culture sensitivity.

  • Two broad-spectrum antibiotics for 7 to 14 days (Permapen [penicillin], Principen [ampicillin], and Kantrex [kanamycin]).
  • Garamycin (gentamicin) may be used if resistance to other antibiotics.

Maternal–Newborn Nursing: Drug-Dependent Newborn

Focus topic: Maternal–Newborn Nursing

Characteristics
A. There is a direct relationship between the duration of addiction, dosage, and the severity of symptoms.
B. Cocaine has largely replaced heroin and methadone as addictive substances.
C. Heroin-addicted mother: Infant may appear normal at birth with a low birth weight.

  • Onset of withdrawal begins within 72 hours, but may not begin until up to 2 weeks after birth.
  • Infant appears less ill than when mother is taking methadone.
  • Heroin causes early maturity of the liver.

D. Mother on methadone.

  • Onset of withdrawal may be delayed; most evident after 48–72 hours and may last 6 days to 8 weeks.
  • Infant may appear to be very ill.
  • May develop jaundice due to prematurity.

E. Mother addicted to cocaine.

  • A stimulant; maternal-to-fetal transfer of cocaine is swift, with the metabolites even more potent than the drug.
  • Infant evidences decreased interactive behavior, feeding problems, irregular sleep patterns, diarrhea.
  • Seven out of 1000 mothers will have infants with major deformities—especially of the kidneys.

Assessment
A. Assess for irritability, jitteriness, tremors, hyperactivity, and hypertonicity.
B. Assess for respiratory distress and ventilatory capacity.
C. Observe for the following signs:

  • Persistent, high-pitched, shrill cry.
  • Sneezing, yawning, nasal stuffiness.
  • Fever.
  • Disruption of normal sleep patterns.
  • Gastrointestinal effects.
    a. Vomiting.
    b. Diarrhea.
    c. Poor feeding.
    d. Hunger, sucking fists.
  • Excessive sweating.
  • Extreme sucking of fists.

D. Assess for convulsions, which are rare.

Implementation
A. Monitor respiratory and cardiac rates every 30 minutes and prn.
B. Take temperature every 4 to 8 hours and prn.
C. Reduce external stimuli and handle infant infrequently.

  • Hold infant firmly and close to body during feedings and when giving care.
  • Maintain warmth and swaddle infant in blanket.

D. Pad sides of crib to protect infant from injury.
E. Administer small, frequent feedings by gavage if necessary.
F. Suction if necessary.
G. Provide careful skin care: cleanse buttocks and anal area carefully.
H. Measure I&O.
I. Keep mother informed of infant’s progress.
J. Promote mother’s interest in infant.
K. Administer medications as ordered, usually paregoric (narcotic opiate), Luminal, Solfoton (phenobarbital), Valium (diazepam), tincture of opium.

  • Controls behavioral/neurological and GI symptoms.
  • Drug alleviates substance withdrawal and is slowly withdrawn.

Maternal–Newborn Nursing: Fetal Alcohol Syndrome

Focus topic: Maternal–Newborn Nursing

Characteristics
A. Maternal alcohol abuse throughout pregnancy results in fetal alcohol syndrome. Also called fetal alcohol spectrum disorder (FASD).

  • Most serious cause of teratogenesis.
  • Affected infants.
    a. Prenatal and postnatal growth deficiency (SGA).
    b. CNS dysfunction—mental retardation.
    c. Craniofacial feature: microencephaly, short palpebral (eyelid) fissures, thin upper lip, flat midface.

B. Lesser amount of alcohol ingested throughout pregnancy results in less severe symptoms—identified as fetal alcohol effect (FAE).

  • Studies suggest that 1 ounce/day presents a significant risk to the fetus and 2 ounces almost always affects the fetus.
  • Children suffer long-term neurological effects.
  • Developmental delay and later learning disabilities.
  • Malformations of the skeletal system.
  • May not be diagnosed until early childhood.

Assessment
A. Monitor for respiratory distress and apnea.
B. Observe for cyanosis.
C. Observe for seizures.
D. Check for major brain dysfunction symptoms.

Implementation
A. Position on side to facilitate drainage of secretions.

  • Keep resuscitation equipment at bedside.
  • Have suction available, especially following feeding.

B. Administer small feedings and burp well.
C. Avoid heat loss.
D. Reduce environmental stimuli.

FURTHER READING/STUDY:

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