Postterm Infant

Over 42 weeks of gestation.

  1. General aspects
    1. Labor may be hazardous for mother and fetus because:
      1. Large size of infant contributes to cephalopelvic disproportion; obtain estimate of fetal weight (EFW) by ultrasound.
      2. Placental insufficiency-fetal hypoxia; diagnosis by:
        1. Contraction stress test.
        2. Nonstress test
        3. Amniotic fluid index (AFI).
      3. Meconium passage (common physiological response) increases chance of meconium aspiration.
  2. Assessment:
    1. If postmature skin: dry, wrinkled-due to metabolism of fat and glycogen reserves to meet in utero energy needs.
    2. Long limbs, fingernails, and toenails-due to continued growth in utero.
    3. Lanugo and vernix-absent.
    4. Expression: wide-eyed, alert-probably due to chronic hypoxia (oxygen hunger).
    5. Placenta-signs of aging.
  3. Analysis/nursing diagnosis: High risk for injury related to high incidence of morbidity and mortality due to dystocia or hypoxia.
  4. Nursing care plan/implementation:
    1. During labor:
      1. Goal: emotional support of mother-may require cesarean birth due to CPD or fetal distress.
      2. Goal: continuous electronic monitoring of FHR. Report late decelerations immediately (indicate fetal distress).
    2. Afterbirth:
      1. Goal: if born vaginally, prompt identification of birth injuries, respiratory distress. Continual observation.
      2. goal: early identification/treatment of emerging signs of complications.
        1. Hypoglycemia-Dextrostix readings and behavior.
        2. Administer oral or intravenous glucose, as ordered.
  5. Evaluation/outcome criterion: successful transition to extrauterine life (all assessment findings within normal limits).

Congenital Disorders

  1. General overview: Genetic abnormalities and environmental insults often lead to congenital disorders of the newborn. Successful transition to independent extrauterine life may pose a major challenge to infants compromised by anatomical or physiological disorders. Knowledge regarding the implications of the neonate’s structural or metabolic problems enables the nurse to identify early signs of health problems and to plan, provide, and evaluate appropriate outcome-directed care to safeguard the status of the infant with a congenital disorder.

  2. Disorders affecting fluid-gas transport: congenital heart disease
    1. Pathophysiology-altered hemodynamics, due to persistent fetal circulation or structural abnormalities.
      1. Acyanotic defects-no mixing of blood in the systemic circulation.
        1. Patent ductus arteriosus.
        2. Atrial septal defect.
        3. Ventriclar septal defect.
        4. Coarctation of the aorta.
      2. Cyanotic defects-unoxygenated blood enters systemic circulation.
        1. Tetralogy of Fallot.
        2. Transposition of the great vessels.
    2. Etiology-unknown. Associated with maternal:
      1. Prenatal viral disease (rubella, Coxsackie).
      2. Malnutrition; alcoholism.
      3. Diabetes (poorly controlled).
      4. Ingestion of lithium salts.
    3. Assessment:
      1. Patent ductus arteriosus.
        1. Characteristic machine murmur, mid to upper left sternal border (cardiomegaly); persists throughout systole and most of diastole; associated with a “thrill.”
        2. Widened pulse pressure.
        3. Bounding pulse, tachycardia, “gallop” rhythm.
      2. Atrial septal defect.
        1. Characteristic crescendo/decrescendo systolic ejection murmur.
        2. Fixed S2 splitting.
        3. Dyspnea, fatigue on normal activity.
        4. Medical diagnosis-cardiac catheterization, x-ray.
      3. Ventricular septal defect.
        1. Loud, harsh, pansystolic murmur; heard best at left lower sternal border; radiates throughout precordium. (Note: may be absent-due to high pulmonary vascular resistance-» equalization of interventricular pressure).
        2. Medical diagnosis-cardiac catheterization, ECG, chest x-ray.
      4. Coarctation of the aorta.
        1. Absent femoral pulse.
        2. Late systolic murmur.
        3. Decreased blood pressure in lower extremities.
        4. Medical diagnosis: x-ray.
      5. Tetralogy of Fallot (“blue” baby).
        1. Acute hypoxic/cyanotic episodes.
        2. Limp, sleepy, exhausted; hypotonic extended position-postepisode.
        3. Medical diagnosis-cardiac catheterization.
      6. Transposition of the great arteries.
        1. Cyanotic after crying or feeding.
        2. Progressive tachypnea-attempt to compensate for decreased PaO2, metabolic acidosis.
        3. Heart sounds vary, consistent with defect.
        4. Signs of CHF.
        5. Medical diagnosis-cardiac catheterization, x-ray, ECG.
    4. Analysis/nursing diagnosis:
      1. Fluid volume excess related to persistent fetal circulation, structural abnormalities.
      2. Impaired gas exchange related to abnormal circulation, secondary to pathology.
      3. Altered nutrition, less than body requirements, related to exhaustion, dyspnea.
    5. Nursing care plan/implementation:
      1. Goal: minimize cardiac workload.
        1. Minimize crying-snuggle; pacifier-to meet psychological needs.
        2. Keep clean and dry.
      2. Goal: maintain thermal stability-to reduce body need for oxygen.
      3. Goal: prevent infection.
        1. Strict aseptic technique; standard precautions.
        2. Hand washing.
      4. Goal: parental emotional support.
        1. Encourage verbalization of anxiety, fears, concerns.
        2. Keep informed of status.
      5. Goal: health teaching-explain, discuss:
        1. Diagnostic procedures.
        2. Treatment procedures.
        3. Basic care modalities.
      6. Goal: promote bonding. Encourage to participate in infant care, as possible.
      7. Medical/surgical management: surgical intervention/repair of congenital cardiac abnormality.
    6. Evaluation/outcome criteria:
      1. Experiences no respiratory distress in immediate postnatal period.
      2. Completes transfer to high-risk center without incident, if applicable.
      3. Surgical intervention successful, where applicable.

  3. Disorders affecting fluid-gas transport: hemolytic disease of the newborn
    1. Rh incompatibility
      1. Pathophysiology
      2. Etiology
      3. Assessment:
        1. Prenatal-maternal Rh titers, amniocentesis.
        2. Intrapartal-amniotic fluid color:
          1. Straw-colored: mild disease.
          2. Golden: severe fetal disease.
        3. Direct Coombs’ blood; positive test demonstrates Rh antibodies in fetal blood.
      4. Nursing care plan/implementation-exchange transfusion:
        1. Goal: health teaching.
          1. Explain purpose and process to parents.
          2. Removes anti-Rh antibodies and fetal cells that are coated with antibodies.
          3. Reduces bilirubin levels-indicated when 20 mg/dl in term neonate and 15 mg/dl in preterm.
          4. Corrects anemia-supplies RBCs that will not be destroyed by maternal antibodies.
          5. Rh-negative type O blood elicits no reaction; maximum exchange is 500 mL; duration of exchange: 45-60 minutes.
        2. Goal: minimize transfusion hazards.
          1. Warm blood to room temperature, since cold blood may precipitate cardiac arrest.
          2. Use only fresh blood-to reduce possibility of hypocalcemia, tetany, convulsions.
          3. Give calcium gluconate, as ordered, after each 100 mL of transfusion.
        3. Goal: prepare for transfusion procedure. Ready necessary equipment-monitor, resuscitation equipment, radiant heater, light.
        4. Goal: assist with exchange transfusion.
          1. Continuous monitoring of vital signs; record baseline, and every 15 minutes during procedure.
          2. Record: time, amount of blood withdrawn; time and amount injected; medications given.
          3. Observe for dyspnea, listlessness, bleeding from transfusion site, cyanosis, cardiovascular irregularity or arrest; coolness of lower extremities.
        5. Goal: posttransfusion care.
          1. Assessment:
            1. Observe for dyspnea, cyanosis, cardiac arrest or irregularities, jaundice, hypoglycemia; frequent vital signs.
            2. Signs of sepsis-fever, tachycardia, dyspnea, chills, tremors.
          2. Nursing care plan/implementation:
            1. Maintain thermal stability-to reduce physiological stress, possibility of metabolic acidosis.
            2. Give oxygen-to relieve cyanosis.
            3. Keep cord moist-to facilitate repeat transfusion, if necessary.
            4. Maintain nutrition/hydration- feed per schedule.
      5. Evaluation/outcome criteria:
        1. Infant’s hemolytic process ceases; bilirubin level drops.
        2. Infant makes successful transition to extrauterine life.
        3. Infant experiences no complications of therapeutic regimen.
        4. Infant shows evidence of bonding.