Chapter 13 Preterm and Postterm Newborns

___ _____ refers to the actual time, from conception to birth, that the fetus remains in the uterus. Gestational age For the preterm infant this is less than ___weeks. 37 An early term infant is born between ____ and ____. An early term infant is born between 37 weeks and 38 weeks, 6 days. The full term infant is one born between _____ and ____ 39 and 40 weeks, 6 days late term infant is one born between _____ and _____.. late term infant is one born between 41 weeks and 41 weeks, 6 days. The postterm infant is born beyond ____ weeks 42 One standardized method used to estimate gestational age within 1 to 2 weeks is the ____ ____ system Ballard scoring system The Ballard scoring system is based on what two things? the infant's external characteristics and neurological development List three methods used to evaluate the gestational age of the newborn infant. The Ballard score, the estimated gestational age based on the mother's last normal menstrual period, and ultrasound evaluations _______ refers to how well developed the infant is at birth and the ability of the organs to function outside the uterus. Level of maturation What is the skin like in a preterm newborn? transparent and loose. Superficial veins may be seen beneath the ___ and ____ abdomen and scalp. List eight physical characteristics of the preterm infant. There is a lack of subcutaneous fat. Fine hair (lanugo) covers the forehead, shoulders, and arms. The cheeselike vernix caseosa is abundant. The extremities appear short. The soles of the feet have few creases. The abdomen protrudes. The nails are short. The genitalia are small. _______ is a result of lung immaturity, which leads to decreased gas exchange. RDS type 1 With RDS type 1, there is a deficient synthesis or release of __________. surfactant Surfactant is high in _______, a fatty protein necessary for the absorption of oxygen by the lungs lecithin Testing for the ______________ ratio provides information about the amount of surfactant in amniotic fluid. lecithin/sphingomyelin (L/S) What are three symptoms of respiratory distress syndrome that signify that it is more severe? Edema, lassitude, and apnea Surfactant begins to appear in the fetal alveoli at approximately ____ weeks of gestation and is at a level to enable the infant to breathe adequately at birth by _______ weeks of gestation. Surfactant begins to appear in the fetal alveoli at approximately 24 weeks of gestation and is at a level to enable the infant to breathe adequately at birth by 34 weeks of gestation. If insufficient amounts of surfactant are detected through amniocentesis, it is possible to increase its production by giving the mother injections of corticosteroids such as ________. betamethasone In preterm newborns, surfactant can be administered via endotracheal (ET) tube at birth or when symptoms of RDS occur, with improvement of lung function seen within ___ hours. 72 _________ _______ is the toxic response of the lung to oxygen therapy. Bronchopulmonary dysplasia Apnea is defined as the cessation of breathing for ____ seconds or longer. 20 What is apnea in the pretterm newborn believed to be related to? is believed to be related to immaturity of the nervous system. What may first be done to stimulate breathing? Gentle rubbing of the infant's feet, ankles, and back When gentle rubbing of the infant's feet, ankles, and back doesn't work, what may be done? suctioning of the nose and mouth and raising of the infant's head to a semi-Fowler's position usually facilitates breathing. Define pulse oximetry the measure of oxygen on the hemoglobin in the circulating blood divided by the oxygen capacity of the hemoglobin. A pulse oximeter saturation level of _____% or higher is normal 92 There must be at least ____ g/dL of desaturated hemoglobin (unoxygenated blood) to produce clinical cyanosis. 5 The severely ______ infant may have severe hypoxia yet not manifest clinical cyanosis. anemic If the hemoglobin present is an abnormal fetal hemoglobin, ________ can be present even when the pulse oximeter shows a normal reading, because fetal hemoglobin does not readily release oxygen to the tissues and end organs hypoxia Why are preterm newborns at risk for developing sepsis because of the immaturity of many body systems. List four specific examples of immature body systems that puts preterm newborns at risk for developing sepsis. The liver of the preterm infant is immature and forms antibodies poorly. Body enzymes are inefficient. There is little or no immunity received from the mother, and stores of nutrients, vitamins, and iron are insufficient. Set alarm switch to minimum acceptable oxygen saturation (Sao2) of approximately ___ to ___ % 92%-95%. Treatment for sepsis of the preterm infant involves what three things? administration of intravenous antimicrobials, maintenance of warmth and nutrition, and close monitoring of vital signs, including blood pressure. Heat loss in the preterm infant results from the following factors: (7) •Lack of brown fat, which is the body's insulation. •Excessive heat loss by radiation from a surface area that is large. (head) •The heat-regulating center of the brain is immature. •The sweat glands are not functioning to capacity. •The preterm infant is inactive, has muscles that are weak and are less resistant to cold, and cannot shiver •Legs are extended. This increases the surface area exposed to the environment and increases heat loss. •Metabolism is high, and the preterm infant is prone to low blood glucose levels (hypoglycemia). Cold stress increases the need for what two things? Oxygen and glucose Signs and symptoms of cold stress include the following: (5) •Decreased skin temperature •Increased respiratory rate with periods of apnea •Bradycardia •Mottling of skin •Lethargy Why is a skin probe used to monitor the temperature of preterm infants? Because the infant's skin temperature will decrease before the core temperature falls. Where is the skin probe placed? in the right upper quadrant of the abdomen. The temperature of the incubator is adjusted so that the infant's body temperature is at an optimal level which is what? 36.2° to 37° C [97.1° to 98.6° F Plasma glucose levels lower than _____ mg/dL indicate hypoglycemia in a term infant, and in a preterm infant, lower than _____ mg/dL. Plasma glucose levels lower than 40 mg/dL indicate hypoglycemia in a term infant, and in a preterm infant, lower than 30 mg/dL. Calcium is transported across the placenta throughout pregnancy, but in greater amounts during the ______ trimester. third In _____ hypocalcemia the parathyroid fails to respond to the preterm infant's low calcium levels. early Infants stressed by what three conditions are at high risk for early hypocalcemia. hypoxia or birth trauma or who are receiving sodium bicarbonate Infants born to mothers who are ______ or who have had low ______ intake are also at risk for developing early hypocalcemia. diabetic: vitamin D _____ hypocalcemia usually occurs about age 1 week in newborn or preterm infants who are fed cow's milk. Late What is the treatment for hypocalcemia? Administering intravenous calcium gluconate During intravenous therapy of calcium gluconate, the nurse should monitor the infant for what? bradycardia. Signs of hypoglycemia in the preterm infant include the following: (5) •Tremors •Weak cry •Lethargy •Convulsions •Plasma glucose level lower than 40 mg/dL (term) or 30 mg/dL (preterm) Preterm infants are more prone to bleeding than full-term infants because their blood is deficient in _______, a factor of the clotting mechanism. prothrombin Fragile capillaries of the head are particularly susceptible to injury during delivery, causing _____ ____. intracranial hemorrhage. Why are premature infants at risk for Retinopathy of prematurity (ROP)? because their immature retinas are incompletely vascularized at birth. After birth, often accompanied by high levels of oxygen required for the infant's survival, the retina completes an abnormal vascularization process that causes _______ tissue to form behind the lens of each eye resulting in blindness and retinal detachment fibrous Maintaining a sufficient level of ______ and avoiding excessively high concentrations of ______ may help to prevent this condition. vitamin E;oxygen The infant's ability to absorb ____ is poor . Fats. These include fat-soluable vitamins _________ is an acute inflammation of the bowel that leads to bowel necrosis. Necrotizing enterocolitis (NEC) Factors implicated for necrotizing enterocolitis (NEC) include a diminished blood supply to the lining of the bowel wall because of ______ or ______ that causes a decrease in protective mucus and results in bacterial invasion of the delicate tissues. Hypoxia or sepsis List four signs of NEC abdominal distention, bloody stools, diarrhea, and bilious vomitus. How do you determine the urine output of an infant? The nurse should weigh the dry diaper and subtract its weight from the infant's wet diaper The urine output should be between ____ and ____ 1 and 3 mL/kg/hr. With jaundice, the liver is unable to clear the blood of ______ pigments that result from the normal postnatal destruction of red blood cells. bile An increase of more than ______ mg/dL in 24 hours or a bilirubin level greater than _____ mg/dL requires careful investigation An increase of more than 5 mg/dL in 24 hours or a bilirubin level greater than 12.9 mg/dL requires careful investigation ______ jaundice is more serious, occurs within 24 hours of birth, and is secondary to an abnormal condition such as ABO-Rh incompatibility Pathological There is more evidence of jaundice in infants who are ______.. breastfed What should not be given to the infant who has jaundice? Why? Glucose water feedings should not be offered to the infant, because this practice may decrease milk intake and can serve to further increase bilirubin levels In late-onset jaundice of the breastfed infant, the breast milk itself may inhibit conjugation of bilirubin, and therefore formula may be substituted for ____ to ____ hours to reduce bilirubin levels. 24 to 48 The total serum bilirubin level typically peaks ___ to ___ days after birth. 3 to 5 The goals of treatment for hyperbilirubinemia are to prevent_______ and to avoid _____. kernicterus (a serious neurological complication that can cause brain damage, which is also known as bilirubin encephalopathy) and to avoid the continued increase of bilirubin levels in the blood. The nurse records the temperature of the infant and the incubator every _______. 2 hours. A relative humidity of ___% or higher is desirable. 60 ___ _____ is a method of care for preterm infants that uses skin-to-skin contact. Kangaroo care The ability to coordinate breathing, sucking, and swallowing does not develop before ___ weeks of gestation. 34 If a residual of liquid contents is aspirated before the feeding is started, what should be done? the physician should be notified before proceeding to feed the infant. Formulas designed for the term infant are not well tolerated by preterm infants because they are a burden to their kidneys and can cause what sort of problems? central nervous system problems Why are formulas designed for preterm infants not well tolerated by infants older than 34 weeks of gestation or term infants? because hypercalcemia may develop. If the infant is gavage fed, the tube is replaced every __ to ____ days. 3 to 7 Why are preterm newborns positioned on the side or prone, with the head of the mattress slightly elevated, if not contraindicated? the abdominal contents do not press against the diaphragm and impede breathing. List four advantages to propping the infant on the side or placing the infant prone It can decrease respiratory effort, improve oxygenation, promote a more organized sleep pattern, and lessen physical activity that burns up energy needed for growth and development. In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the _____ year. second _______ refers to the infant showing characteristics of the postmature syndrome. Postmaturity The following problems are associated with postmaturity: (7) •Asphyxia caused by chronic hypoxia while in the uterus because of a deteriorated placenta •Meconium aspiration: hypoxia and distress may cause relaxation of the anal sphincter, and meconium can be aspirated into the fetal lungs •Poor nutritional status; depleted glycogen reserves cause hypoglycemia •Increase in red blood cell production (polycythemia) because of intrauterine hypoxia •Difficult delivery because of increased size of the infant •Birth defects •Seizures as a result of the hypoxic state List 8 physical characteristics of the postterm infant. long, thin, loose skin, little lanugo, little vernix, dry, cracked skin, thick head of hair, and long nails. In general, growth and development of the preterm infant are based on current age minus __________. the number of weeks before term that the infant was born; for example, if born at 36 weeks of gestation, a 1-month-old infant would be at a newborn's achievement level. List three things that nurses observe for in a postterm infant. respiratory distress (usually because of aspiration of meconium-stained amniotic fluid), hypoglycemia (caused by depleted glycogen stores), and hyperbilirubinemia (as a result of polycythemia). Gestational Age actual time from conception to the birth that ftus remains in uterus preterm less than 38 weeks Term 38 to 42 weeks Postterm greater than 42 weeks ballard score standard method used to determine gestational age based on external characteristics and neurological development What is the leading cause of death in the first year of an infant? preterm birth late preterm infant (near term infant ) born between 24 and 36 weeks also considered high risk regardless of weight Level of maturation how well developed the infant is at birth ability of the organs to function outside the uterus. Physical characteristic of a preterm infant skin transparent and loose superficial veins may be seen beneath the abdomen and scalp lack of subcutaneous fat fine hair (lanugo) cover the forehead, shoulder, and arms vernix caseose abudant extremities appear short soles of the feet have few creases abdomen protrudes nails are short genitalia are small girl the labia majora may be open Causes of preterm births -multiple births -Maternal illness ( GH, UTI, preclampsia) -placental abnormalities (placenta previa, premature separation of the placenta from uterine wall During the second half of the pregnancy what changes occur in the fetal lungs alveoli (air sacs) enlarge and bring them close to the capillaries in the lungs Failure of the alveoli to enlarge is called ? previability If born premature what effect doe this have on the lungs? -muscles that move the chest are not fully developed -abdomen is distended, creating pressure on the diaphragm - stimulation of the respiratory center in the brain is immature -gag and cough reflex are weak because immature nerve supply Respiratory distress syndrome (RDS type 1) (hyaline membrane disease) result of immature lung, leads to decreased gas exchange surfactant is a fatty protein that is high in lecithin, it necessary for the lung to absorb oxygen Symptoms of respiratory distress -respiration increase to 60 breaths per min - tachypnea are accompanied by gruntlike sounds, nasal flaring, cyanosis, and intercostal and sternal retraction. -Edema, lessatude, and apnea as condition becomes more severe -mechanical ventilation may be required Treatment of respiratory distress Increase surfactant production by giving the mother injections of corticosteroids such as betamethasone 1 or 2 days before delivery Treatment of preterm infant with respiratory distress surfactant can be administered via ET tube at birth or when symptoms occur improvement usually seen within 72 hours What can alter surfactant production? during cold stress hypoxia poor tissue profusion Care of infant with RDS -monitor vital sounds - minimal handling to help conserve energy(cluster care) - observe for sign of under or over hydration -Oxygen therapy, monitor pulse oximety , infant on supplemental oxygen is at high risk for oxygen toxicity what is bronchopulmonary dysplasia? toxic response of the lung to oxygen therapy what are risk with bronchopulmonary dysplasia atelectasis (collapsed lung) , edema and thickening of the membrane of the lung interferes with ventilation often results in prolonged dependency on supplemental oxygen and ventilators and has long term complications apnea cessation of respiration for 20 sec or longer neonatal hypoxia inadequate oxygenation at the cellular level in a new born infant hypoxemia Deficiency of oxygen in the arterial blood What are the normal saturation levels 92% or above Sepsis generalized infection of the blood Why are preterms at risk for developing sepsis - immaturity of many body systems - liver is immature poor formation of antibodies - body enzymes are inefficient - maternal infection or complications during labor Symptoms of sepsis are - low temp - lethargy or irritability - poor feeding - respiratory distress Treatment of sepsis is? -administration of IV antibiotics - maintain warmth and nutrition - Close monitor VS - Cluster care to conserve energy - follow standard precautions what factors cause a preterm infant to lose heat -lack of brown fat , bodies insulation - excessive heat loss from radiation from a surface area that is large in portion to the body - the heat regulation center of the brain is in mature - sweat glands are not functioning to capacity -preterm infant is inactive, has muscles that are weak and less resistant to cold, unable to shiver -preterm body position is one of leg extension -high metabolism prone to low blood glucose levels Sign and symptoms of cold stress -Increase respiratory rate with periods of apnea - decrease skin temp - bradycardia - mo - Mottling of skin - lethargy Will have an increase need for oxygen and glucose hypoglycemia common in preterm low blood sugar ("hypo" less than ") ("glycemia" sugar in blood) What are plasma glucose in term infant 40 mg/dl What are plasma glucose in preterm infant 30 mg/dl Any condition that increases metabolism increase what need? glucose Hypocalcemia Low calcium in blood ("hypo" below ") ("calcemia" calcium in blood)