Module 8: Newborns at Risk

Comprehensive Study Guide

📊 Classifications by Gestational Age and Birth Weight

🚨 CRITICAL CONCEPT

The more premature the infant, the greater the risk for ALL complications!

Remember: Gestational age is the STRONGEST predictor of neonatal outcomes.

Classification	Definition	Key Characteristics	Primary Concerns
Extremely Preterm	<28 weeks	• Translucent skin • Fused eyelids • No ear cartilage • Minimal subcutaneous fat	• Survival 80-90% • High risk IVH, ROP • Chronic lung disease • Neurodevelopmental issues
Very Preterm	28-32 weeks	• Thin skin • Some ear cartilage • Weak suck • Poor tone	• RDS common • Feeding difficulties • Temperature instability • Apnea of prematurity
Late Preterm	34 0/7 - 36 6/7 weeks	• Look mature • May have good tone • Inconsistent feeding • Sleepy	• Hypoglycemia • Jaundice • Feeding problems • Readmission risk
Term	37-42 weeks	• Full subcutaneous fat • Good muscle tone • Strong suck • Alert periods	• Transition issues • Birth injuries • Congenital anomalies
Post-term	>42 weeks	• Peeling skin • Long nails • Meconium staining • Alert, wide-eyed	• Meconium aspiration • Hypoglycemia • Polycythemia • Poor placental function

Birth Weight Classifications

Category	Weight	Percentile	Associated Risks
ELBW (Extremely Low)	<1000g	N/A	• Mortality 10-50% • All preterm complications • Long NICU stay
VLBW (Very Low)	<1500g	N/A	• IVH risk 25% • NEC risk 7% • ROP requiring treatment
LBW (Low)	<2500g	N/A	• Feeding difficulties • Temperature instability • Hypoglycemia
SGA (Small for GA)	Any	<10th	• Hypoglycemia • Polycythemia • Temperature instability
AGA (Appropriate)	Any	10th-90th	• Based on GA
LGA (Large for GA)	Any	>90th	• Birth trauma • Hypoglycemia • Respiratory issues

👶 Comprehensive Preterm Infant Management

PRETERM Care Priorities:
Pulmonary support
Regulate temperature
Electrolyte balance
Touch gently (skin care)
Eat (nutrition)
Reduce stimulation
Monitor for complications

System-by-System Assessment and Management

🫁 Respiratory System

Assessment:

Respiratory rate (normal: 30-60)
Work of breathing (retractions, grunting)
Color (central cyanosis = emergency)
O2 saturation (target: 90-95% for preterm)
Blood gases

Interventions:

Position: prone or side-lying
CPAP for mild distress
Surfactant within 2 hours if indicated
Mechanical ventilation if severe
Gentle suctioning only as needed

🌡️ Thermoregulation

Assessment:

Axillary temp q1-2h initially
Signs of cold stress: ↓ temp, ↑ O2 needs
Environmental temperature
Skin color and perfusion

Interventions:

Radiant warmer or incubator
Plastic wrap for ELBW in delivery room
Warm blankets, hat
Kangaroo care when stable
Gradual weaning to open crib

💧 Fluid & Electrolytes

Assessment:

Weight (expect 5-15% loss)
Urine output (1-3 mL/kg/hr)
Skin turgor, fontanels
Electrolytes q8-12h initially
Blood glucose

Interventions:

IV fluids: start 60-80 mL/kg/day
Increase by 10-20 mL/kg/day
Humidified environment for ELBW
Monitor for SIADH
Careful I&O documentation

🍼 Nutrition

Assessment:

Feeding readiness cues
Suck-swallow-breathe coordination
Gastric residuals
Abdominal girth
Stool pattern

Interventions:

TPN initially for VLBW
Trophic feeds: 10-20 mL/kg/day
Advance slowly: 20 mL/kg/day
Fortify breast milk at 100 mL/kg/day
Non-nutritive sucking

⚠️ Major Complications of Prematurity

⚠️ Remember: The earlier the gestation, the higher the risk AND severity of ALL complications!

1. Respiratory Distress Syndrome (RDS)

Aspect	Details
Pathophysiology	• Surfactant deficiency → alveolar collapse • Peak incidence: 24-28 weeks (60-80%) • Decreases with advancing GA
Clinical Signs	• Onset within minutes to hours • Tachypnea (>60) • Grunting, nasal flaring • Retractions (subcostal, intercostal) • Cyanosis in room air
Diagnostics	• CXR: ground glass, air bronchograms • ABG: hypoxemia, hypercarbia • ↓ lung compliance
Management	• IMMEDIATE: CPAP in delivery room • Surfactant within 2 hours • Mechanical ventilation if CPAP fails • Target SpO2 90-95% • Minimal handling

2. Bronchopulmonary Dysplasia (BPD)

Definition: O2 requirement at 36 weeks postmenstrual age OR >28 days of life

Severity	O2 Requirement at 36 weeks PMA	Management Focus
Mild	Room air	• Monitor growth • RSV prophylaxis
Moderate	<30% O2	• Diuretics PRN • Nutrition optimization
Severe	≥30% O2 or PPV	• Steroids considered • Home O2 likely

3. Intraventricular Hemorrhage (IVH)

Grade	Location	Outcomes	Nursing Care
I	Germinal matrix only	Usually good	• Minimal stimulation • Midline positioning
II	Into ventricle, no dilation	90% normal development	• Cluster care • Monitor HC daily
III	With ventricular dilation	35% severe disability	• Elevate HOB 30° • Serial HUS
IV	Parenchymal involvement	90% severe disability	• Prepare for VP shunt • Seizure precautions

🚨 IVH Prevention Bundle: • Delayed cord clamping • Minimal handling first 72h • Midline head position • Avoid rapid fluid boluses • Maintain normothermia • Prevent pneumothorax

4. Necrotizing Enterocolitis (NEC)

NEC Warning Signs - "BAD GUT":
Bloody stools
Abdominal distention
Decreased bowel sounds
Gastric residuals ↑
Unstable vitals
Temperature instability

Stage	Clinical Signs	X-ray Findings	Management
I - Suspected	• Feeding intolerance • Mild distention • Guaiac + stools	Normal or ileus	• NPO × 3 days • Antibiotics • Serial exams
II - Definite	• Absent bowel sounds • Tenderness • Metabolic acidosis	Pneumatosis intestinalis	• NPO × 7-14 days • TPN • Antibiotics × 10d
III - Advanced	• Shock • DIC • Peritonitis	Pneumoperitoneum	• Surgery • Pressors • Ventilation

🏥 Acquired Conditions in Newborns

Respiratory Conditions Quick Reference

Condition	Typical Patient	Key Features	Management
TTN (Transient Tachypnea)	• Term/late preterm • C-section • Male	• Onset: birth-2h • Tachypnea only • CXR: wet lungs	• O2 PRN • NPO if RR >60 • Resolves 24-72h
MAS (Meconium Aspiration)	• Post-term • SGA • Fetal distress	• Barrel chest • Coarse crackles • CXR: patchy infiltrates	• NO deep suctioning • Surfactant • May need ECMO
PPHN (Persistent Pulm HTN)	• Any severe lung disease • Diaphragmatic hernia • Sepsis	• Labile O2 sats • Pre/post ductal difference • Loud S2	• Minimize stimulation • Sedation • iNO • ECMO if severe
Pneumothorax	• Ventilated infants • Meconium • CPAP	• Sudden deterioration • ↓ breath sounds • Shift of heart sounds	• Transillumination • Needle decompression • Chest tube

Hyperbilirubinemia Management

⚠️ KNOW YOUR NOMOGRAM! Treatment thresholds depend on: • Gestational age • Hours of life • Risk factors (hemolysis, G6PD, sepsis)

Type	Onset	Causes	Treatment
Physiologic	Day 2-3	• Normal RBC turnover • Immature liver	• Usually none • Feed frequently
Pathologic	<24 hours	• ABO/Rh incompatibility • G6PD deficiency • Sepsis	• Phototherapy • Exchange transfusion • IVIG for hemolysis
Breast Milk	Day 4-7	• Factors in breast milk • ↓ intake	• Continue breastfeeding • Photo if high

✅ Phototherapy Nursing Care: • Eye protection ALWAYS • Maximize skin exposure • Turn q2h • Monitor temperature • Increase fluids 10-20% • Check bili q6-12h

Sepsis in the Newborn

Type	Timing	Common Organisms	Risk Factors
Early-Onset	<72 hours	• GBS (#1) • E. coli • Listeria	• Maternal GBS+ • PROM >18h • Maternal fever
Late-Onset	>72 hours	• CONS • S. aureus • Candida	• Central lines • VLBW • Prolonged antibiotics

🚨 Subtle Signs of Sepsis: "Not Acting Right" • Temperature instability (high OR low) • Feeding intolerance • Lethargy • Irritability • Apnea • Glucose instability • "Just doesn't look good"

Infant of Diabetic Mother (IDM)

Problems to Anticipate

Hypoglycemia (30-50%)
Macrosomia → birth trauma
RDS (insulin ↓ surfactant)
Polycythemia
Hypocalcemia
Hypomagnesemia
Cardiac defects

Management Protocol

Blood glucose at 30min, 1h, 2h, 4h
Feed within 30 minutes
IV glucose if BG <40 mg/dL
Check Ca++ at 24h
Echo if murmur
Monitor for plethora

💊 Neonatal Abstinence Syndrome (NAS)

NAS Assessment - "WITHDRAWS":
Wakefulness (↑)
Irritability
Tremors
High-pitched cry
Diarrhea
Respiratory distress
Autonomic dysfunction
Weight loss
Seizures (severe)

Drug Class	Onset of Symptoms	Duration	Key Features
Opioids	24-72 hours	Days to weeks	• Classic NAS • Finnegan score • May need morphine
Cocaine	Birth-48 hours	2-3 days	• Jittery • Poor feeding • No pharmacologic tx
Methamphetamine	Birth-24 hours	Days	• Agitation • Poor sleep • SGA common
SSRIs	Birth-48 hours	2-4 days	• Mild symptoms • Supportive care only

📋 Finnegan Scoring: • Score q4h after feeding • Start within 2h of birth • Score ≥8 × 2 consecutive = start treatment • Score ≥12 × 1 = start treatment

🧬 Congenital Conditions

Congenital Heart Defects - Presentation by Age

Timing	Defects	Why This Timing?	Key Signs
Day 1	• TGA • TAPVR • Hypoplastic left heart	Depend on mixing	• Cyanosis • Tachypnea • Poor perfusion
Day 2-7	• Coarctation • Critical AS • Interrupted arch	PDA closing	• Shock • Weak pulses • Acidosis
Week 2-8	• Large VSD • Large PDA • AV canal	↓ PVR	• CHF signs • Poor feeding • Sweating

🚨 Prostaglandin E1 (PGE1) for Ductal-Dependent Lesions: • Dose: 0.05-0.1 mcg/kg/min • Keep PDA open • Side effects: Apnea (intubate before transport!), fever, flushing

Neural Tube Defects

Type	Description	Immediate Care	Long-term Issues
Anencephaly	Absence of brain/skull	Comfort care only	Incompatible with life
Encephalocele	Brain tissue herniation	• Protect sac • Neurosurg consult	Depends on location/size
Spina Bifida Occulta	Vertebral defect only	None urgent	Usually asymptomatic
Myelomeningocele	Spinal cord + meninges	• Sterile saline dressing • Prone position • Surgery <24h	• Paralysis below • Bowel/bladder • Hydrocephalus

GI/GU Malformations

⚠️ Tracheoesophageal Fistula (TEF) - The 3 C's: • Choking • Coughing • Cyanosis with feeds IMMEDIATE: NPO, elevate HOB, continuous sump suction!

Condition	Key Features	Immediate Management
Diaphragmatic Hernia	• Scaphoid abdomen • Respiratory distress • Bowel sounds in chest	• Intubate immediately • OG to decompress • NO bag-mask!
Omphalocele	• Covered defect • Central • Associated anomalies	• Cover with plastic wrap • NG decompression • IV fluids
Gastroschisis	• No covering • Right of umbilicus • Usually isolated	• Bowel in bag to umbilicus • Position right side • Temp support
Imperforate Anus	• No anal opening • May have fistula • Associated with VATER	• NPO • NG decompression • Surgery timing varies

🏠 Discharge Planning for High-Risk Infants

✅ Discharge Criteria for Preterm Infants: • Maintaining temperature in open crib × 24-48h • Taking all feeds PO with weight gain • No apnea/bradycardia × 5-7 days • Parents demonstrate competent care

Parent Education Priorities

Before Discharge

CPR certification
Car seat test (90-120 min)
Feeding demonstration
Medication administration
Signs of illness
When to call provider
Equipment use (if needed)

Follow-up Needs

PCP within 48-72h
Specialty clinics PRN
Early intervention referral
Hearing screen passed
ROP exam scheduled
Synagis if eligible
Home health if needed

💔 Supporting Families Through Perinatal Loss

Remember: How you support the family in the first hours impacts their grief journey forever. Your calm, compassionate presence matters more than perfect words.

DO	DON'T
• Use baby's name • Offer memory making • Allow unlimited time • Follow their lead • Provide privacy • Offer chaplain/support	• Rush any decisions • Use clichés ("better now than later") • Avoid the topic • Make decisions for them • Judge their reactions • Forget the partner's grief

📋 Quick Reference: Must-Know Values

Parameter	Normal Range	Critical Values
Blood Glucose	45-120 mg/dL	<40 or >150
Calcium	7-12 mg/dL	<7 (seizures)
Hematocrit	45-65%	>65 (polycythemia)
Bilirubin (term)	Based on nomogram	>20-25 (kernicterus risk)
Temperature	36.5-37.5°C	<36.5 or >38°C

🚨 EMERGENCY Conditions - Act IMMEDIATELY: • Pneumothorax with shift • Seizures • Shock • Severe hypoglycemia • Complete heart block • Ductal-dependent lesion with closing PDA

✏️ NCLEX-Style Practice Questions

Q1: A 26-week preterm infant is 2 hours old. Which assessment finding requires immediate intervention?
a) Glucose 38 mg/dL
b) Temperature 36.2°C
c) Grunting with subcostal retractions ✅
d) Weight loss of 2%

Rationale: Grunting and retractions indicate respiratory distress (likely RDS), requiring immediate respiratory support.

Q2: The nurse caring for an infant of a diabetic mother should monitor for which complications? (Select all that apply)
✅ Hypoglycemia
✅ Respiratory distress syndrome
✅ Hypocalcemia
✅ Polycythemia
✅ Birth trauma

Rationale: All are common in IDM due to hyperinsulinemia and macrosomia.

Q3: A baby with myelomeningocele is admitted. What is the priority nursing intervention?
a) Obtain blood for genetic testing
b) Cover the sac with sterile saline-soaked gauze ✅
c) Place infant supine for assessment
d) Insert urinary catheter

Rationale: Protecting the sac from rupture and infection is the immediate priority. Position prone, not supine!

🎯 Key Takeaways for NCLEX Success

PREPARE for High-Risk Newborn Questions:
Prioritize ABC's always
Recognize subtle signs
Earlier gestation = higher risk
Prevent complications
Assess continuously
Respond quickly
Educate parents throughout

OB/Maternity Nursing Study Guide

Module 7

Module 8

1. Premature Rupture of Membranes (PROM)

⚠️ Critical Point

📊 Classifications by Gestational Age and Birth Weight

🚨 CRITICAL CONCEPT

Birth Weight Classifications

👶 Comprehensive Preterm Infant Management

System-by-System Assessment and Management

🫁 Respiratory System

🌡️ Thermoregulation

💧 Fluid & Electrolytes

🍼 Nutrition

⚠️ Major Complications of Prematurity

1. Respiratory Distress Syndrome (RDS)

2. Bronchopulmonary Dysplasia (BPD)

3. Intraventricular Hemorrhage (IVH)

4. Necrotizing Enterocolitis (NEC)

🏥 Acquired Conditions in Newborns

Respiratory Conditions Quick Reference

Hyperbilirubinemia Management

Sepsis in the Newborn

Infant of Diabetic Mother (IDM)

Problems to Anticipate

Management Protocol

💊 Neonatal Abstinence Syndrome (NAS)

🧬 Congenital Conditions

Congenital Heart Defects - Presentation by Age

Neural Tube Defects

GI/GU Malformations

🏠 Discharge Planning for High-Risk Infants

Parent Education Priorities

Before Discharge

Follow-up Needs

💔 Supporting Families Through Perinatal Loss

📋 Quick Reference: Must-Know Values

✏️ NCLEX-Style Practice Questions

🎯 Key Takeaways for NCLEX Success