Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Tamag, Vigan City
2700 Ilocos Sur

College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

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NCM 109

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Care of Mother and
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Child at Risk or with
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Problems
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(Acute & Chronic)

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Learning Materials
 [CHAPTER 1: NURSING CARE OF AT RISK/ HIGH-RISK/ SICK
NEWBORN]

COURSE DESCRIPTION

This course deals with concepts, principles, theories and techniques in the nursing care of
at risk/high risk/sick clients during childbearing and childrearing years toward health promotion, disease

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prevention, restoration and maintenance, rehabilitation. The learners are expected to provide safe,
appropriate and holistic nursing care to clients utilizing the nursing process.

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Learning Material (number) deals with:
1. Apply knowledge of principles, social, natural, and health sciences and humanities in managing

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clients, teams and programs in any setting.

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2. Utilize the nursing process in managing a group of clients/ nursing service unit/program in any
setting.
3. Apply guidelines and principles of evidenced-based practice in nursing management.
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4. Apply guidelines and principles of evidenced-based practice in the delivery of care.
5. Communicate effectively in speaking, writing and presenting using culturally appropriate
language to clients and team;
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6. Report and document up-to-date client care accurately and comprehensively.
7. Apply principles of partnership and collaboration to improve delivery of health services.
8. Manage a nursing service unit/ health program in any setting.
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9. Participate in Q/QA activities in a nursing service unit;

10. Participate in varied continuing professional development activities;
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11. Practices the core values of Phil. Nursing profession;

12. Apply techno-intelligent care systems and processes in managing resources and
programs;
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13. Display nursing core values in nursing management and leadership

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LEARNING OUTCOMES
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At the end of the lesson, the students should be able to:

1. Integrate relevant principles of social, physical, natural and health science and humanities in a
given health nursing situations based on epidemiologic profile.

2. Apply appropriate nursing concepts holistically and comprehensively.

PRETEST

A link will be sent by the instructor.

CONTENT

TOPIC 1: PREMATURITY

A PRETERM INFANT

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A preterm infant is traditionally defined

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as a live-born infant born before the end of week 37 of gestation; another criterion used is a weight of
less than 2500 g (5 lb 8 oz) at birth. Preterm birth occurs in approximately 7% of live births of white
infants. In African American infants, the rate is doubled to approximately 14% (Thilo & Rosenberg,

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2008). When a preterm infant is recognized by a gestational age assessment, observe closely for the

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specific problems of prematurity, such as respiratory distress syndrome, hypoglycemia, and intracranial
hemorrhage.
All preterm infants need intensive care from the moment of birth to give them their best chance
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of survival without neurologic after-effects. A lack of lung surfactant makes them extremely vulnerable
to respiratory distress syndrome (Thilo & Rosenberg, 2008). The maturity of a newborn is determined by
physical findings such as sole creases, skull firmness, ear cartilage, and neurologic findings that reveal
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gestational age, as well as the mother’s report of the date of her last menstrual period and sonographic
estimations of gestational age. Preterm babies, regardless of their weight, need to be differentiated at
birth from SGA babies (who also may have a low birth weight). The two conditions result from different
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situations and therefore will cause different problems in adjustment to extrauterine life. A preterm
infant is immature and small but well-proportioned for age. Unlike the SGA infant, this baby appears to
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have been doing well in utero. For an unexplained reason, however, the trigger that initiates labor was
activated too early and birth resulted, even though the baby is immature. Preterm infants are invariably
low birth-weight infants.
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 ETIOLOGY:
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Preterm infant deaths account for 80% to 90% of infant mortality in the first year of life (NVSS,
2009). Infant mortality could be reduced dramatically if the causes of preterm birth could be discovered
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and corrected and all pregnancies brought to term. However, the exact cause of premature labor and
early birth is rarely known. There is a high correlation between low socioeconomic level and early
termination of pregnancy. In women from middle and upper socioeconomic groups, only 4% to 8% of
pregnancies are terminated early. However, in women from low socioeconomic levels, as many as 10%
to 20% end before term. The major influencing factor in these instances appears to be inadequate
nutrition before and during pregnancy, as a result of either lack of money for or lack of knowledge about
good nutrition. Iatrogenic (health care–caused) issues, such as elective cesarean birth and inducing labor
according to dates rather than fetal maturity, also result in preterm births. Testing fetal maturity by
amniocentesis or ultrasound is used to avoid these problems. The increasing use of assisted fertility
methods such as in vitro fertilization that results in multiple births leads to an increased preterm rate as
more multiple pregnancies result in preterm birth than term pregnancies (Goldenberg et al., 2008).

 ASSESSMENT:
On gross inspection, a preterm infant appears small and underdeveloped. The head is
disproportionately large (3 cm greater than chest size). The skin is generally unusually ruddy because
there is little subcutaneous fat beneath it; veins are easily noticeable, and a high degree of acrocyanosis
may be present. The preterm neonate, 24 to 36 weeks, typically is covered with vernix caseosa.
However, in very preterm newborns (less than 25 weeks’ gestation), vernix is absent because it is not

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formed this early in pregnancy. Lanugo is usually extensive, covering the back, forearms, forehead, and
sides of the face, because this amount is present until late in pregnancy. Both anterior and posterior

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fontanelles are small. There are few or no creases on the soles of the feet.
Physical findings and reflex testing are used to differentiate between term and preterm
newborns. The eyes of most preterm infants appear small. Although difficult to elicit, pupillary reaction

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is present. Ophthalmoscopic examination is extremely difficult and often uninformative because the

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vitreous humor may be hazy. A preterm infant has varying degrees of myopia (nearsightedness) because
of lack of eye globe depth.
The ears appear large in relation to the head. The cartilage of the ear is immature and allows the
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pinna to fall forward. The level of the ears should be carefully inspected to rule out chromosomal
abnormalities.
Neurologic function in the preterm infant is often difficult to evaluate as the neurologic system
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is still so immature. The observation of spontaneous or provoked movements may yield findings as
important as reflex testing. If tested, reflexes such as sucking and swallowing will be absent if an infant’s
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age is below 33 weeks; deep tendon reflexes such as the Achilles tendon reflex are also markedly
diminished. During an examination, a preterm infant is much less active than a mature infant and rarely
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cries. If the infant does cry, the cry is weak and high-pitched.
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 POTENTIAL COMPLICATIONS:
 Because of immaturity, preterm infants are prone to several specific conditions.

Anemia of Prematurity. Many preterm infants develop a normochromic, normocytic anemia

(normal cells, just few in number). The reticulocyte count is low because the bone marrow does not
increase its production until approximately 32 weeks. The infant will appear pale and may be lethargic
and anorectic. The fault appears to be immaturity of the hematopoietic system combined with
destruction of red blood cells because of low levels of vitamin E, which normally protects red blood cells
against oxidation. Excessive blood drawing for electrolyte or blood gas analysis can potentiate the
problem. For this reason, keep a record of the amount of blood drawn for analysis. Red blood cell

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production can be stimulated by the administration of DNA recombinant erythropoietin. In addition, an
infant may need blood transfusions to supply needed red blood cells and vitamin E and iron, which can

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be supplemented (Thilo & Rosenberg, 2008).
Kernicterus. Kernicterus is destruction of brain cells by invasion of indirect bilirubin (Symons &
Mahoney, 2008). This invasion results from the high concentrations of indirect bilirubin in the blood

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from excessive breakdown of red blood cells. Preterm infants are more prone to the condition than term

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infants because with the acidosis that occurs from poor respiratory exchange, brain cells are more
susceptible to the effect of indirect bilirubin than usually. Preterm infants also have less serum albumin
available to bind indirect bilirubin and inactivate its effect. Because of this, kernicterus may occur at
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lower levels (as low as 12 mg per 100 mL of indirect bilirubin) in these infants. If jaundice occurs,
phototherapy or exchange transfusion can be initiated to prevent excessively high indirect bilirubin
levels.
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Persistent Patent Ductus Arteriosus. Because preterm infants lack surfactant, their lungs are
noncompliant, so it is more difficult for them to move blood from the pulmonary artery into the lungs.
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This condition leads to pulmonary artery hypertension, which may interfere with closure of the ductus
arteriosus. Administer intravenous therapy cautiously to preterm infants to avoid increasing blood
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pressure and further compounding this problem. Either indomethacin or ibuprofen may be administered
to close the patent ductus arteriosus (Donze, Smith, & Bryowsky, 2007). A side effect of indomethacin is
oliguria, so urine output needs to be monitored closely if this is used.
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Periventricular/Intraventricular Hemorrhage. Preterm infants are prone to periventricular

hemorrhage (bleeding into the tissue surrounding the ventricles) or intraventricular hemorrhage
(bleeding into the ventricles); these conditions occur in as many as 50% of infants of very low birth
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weight (Thilo & Rosenberg, 2008). This occurs because preterm infants have both fragile capillaries and
immature cerebral vascular development. When there is a rapid change in cerebral blood pressure, such
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as with hypoxia, intravenous infusion, ventilation, or pneumothorax, capillaries rupture. An infant

experiences brain anoxia distal to the rupture. Hydrocephalus may occur from bleeding into the
aqueduct of Sylvius with resulting clotting and obstruction of the aqueduct. Preterm infants often have a
cranial ultrasound performed after the first few days of life to detect if a hemorrhage has occurred. An
infant’s prognosis is guarded until it can be shown that development in an infant is progressing normally
after an intracranial bleed.
Other Potential Complications. Preterm infants are particularly susceptible to several illnesses in
the early postnatal period, including respiratory distress syndrome, apnea, retinopathy of prematurity
and necrotizing enterocolitis.
  MANAGEMENT:
A preterm newborn experience a high insensible water loss because of a large body surface relative
to total body weight. Preterm infants also cannot concentrate urine well because of immature kidney
function. Because of this, a high proportion of body fluid is excreted. All these factors make it important
for a preterm baby to receive up to 160 to 200 mL of fluid per kilogram of body weight daily (higher than
the term infant).
1. Intravenous fluid administration typically begins within hours after birth to fulfill this fluid
requirement and provide glucose to prevent hypoglycemia. Intravenous fluid should be given via

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a continuous infusion pump to ensure a constant infusion rate and prevent accidental overload.
Intravenous sites must be checked conscientiously because if infiltration should occur, the lack

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of subcutaneous tissue places a preterm newborn at risk for damaged tissue. Specially designed
27-gauge needles are available for use on small veins. However, many preterm infants lack
adequately sized peripheral veins for even this small a needle. Therefore, they need to receive

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intravenous fluid by an umbilical venous catheter.

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2. Monitor the baby’s weight, urine output and specific gravity, and serum electrolytes to ensure
adequate fluid intake. Too little fluid and calories can lead to dehydration and starvation,
acidosis, and weight loss. Overhydration may lead to no nutritional weight gain, pulmonary
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edema, and heart failure. Most preterm infants void and pass meconium within 24 hours after
birth, although this is delayed in very small infants. Measure urine output by weighing diapers
rather than using urine collection bags, as disposable collection bags can lead to skin irritation
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and breakdown from frequent changing and leaking. The amount of urine output for the first
few days of life in preterm babies is high in comparison with that of the term baby because of
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poor urine concentration: 40 to 100 mL per kg per 24 hours, compared with 10 to 20 mL per kg
per 24 hours.
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3. Also, test urine for glucose and ketones. Hyperglycemia caused by the glucose infusion may lead
to glucose spillage into the urine and an accompanying diuresis. If too little glucose is being
supplied and body cells are using protein for metabolism, ketone bodies will appear in urine.
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Blood glucose determinations every 4 to 6 hours help to determine hypoglycemia or

hyperglycemia (increased serum glucose). Blood glucose should range between 40 and 60
mg/dL. Because of the numerous blood tests performed, be certain to keep a record of all blood
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drawn so an infant does not become hypovolemic from the amount removed. Check for blood in
stools to evaluate possible bleeding from the intestinal tract. This is helpful in determining the
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possible cause of hypovolemia if it occurs.

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 NURSING DIAGNOSIS
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 Impaired gas exchange
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 Altered nutrition
 Ineffective thermo regulation
 Fluid volume deficit
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 Ineffective family coping

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TOPIC 2. POSTMATURITY

THE POST-TERM INFANT

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A post-term infant is one born after the 42nd week of a pregnancy (Fortner, Althaus, & Gurewitsch,
2007). Most nurse-midwives and obstetricians recommend inducing labor at 2 weeks post-term to avoid
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postmature births. However, when gestational age has been miscalculated or if for some other reason
labor is not induced until week 43 of pregnancy or after, the pregnancy may result in a post-term infant.
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An infant who stays in utero past week 42 of pregnancy is at special risk because a placenta appears to
function effectively for only 40 weeks. After that time, it seems to lose its ability to carry nutrients
effectively to the fetus. A fetus who remains in utero with a failing placenta may die or develop post-
term syndrome.

 ASSESSMENT

Infants with this syndrome have many of the characteristics of the SGA infant: dry, cracked, almost
leather-like skin from lack of fluid, and absence of vernix. They may be lightweight from a recent weight
loss that occurred because of the poor placental function. The amount of amniotic fluid may be less at
birth than normal, and it may be meconium stained. Fingernails will have grown well beyond the end of
the fingertips. Such infants may demonstrate an alertness much more like a 2-week-old baby than a
newborn.

When a pregnancy becomes post-term, a sonogram is usually obtained to measure the biparietal
diameter of the fetus. A nonstress test or complete biophysical profile may be done to establish whether
the placenta is still functioning adequately. Cesarean birth may be indicated if a nonstress test reveals
that compromised placental functioning may occur during labor.

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At birth, the post-term baby is likely to have difficulty establishing respirations, especially if
meconium aspiration occurred. In the first hours of life, hypoglycemia may develop because the fetus

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had to use stores of glycogen for nourishment in the last weeks of intrauterine life. Subcutaneous fat
levels may also be low, having been used in utero. This can make temperature regulation difficult,
making it important to prevent a post-term infant from becoming chilled at birth or during transport.

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Polycythemia may have developed from decreased oxygenation in the final weeks. The hematocrit may
be elevated because the polycythemia and dehydration have lowered the circulating plasma level. Any
woman is anxious when she does not have her baby on her due date. She is apt to become extremely
anxious and perhaps angry when it is determined her baby is post-term or should have been born
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earlier. It may seem that if a baby stayed so long in utero, the baby should be extra healthy and strong.
Why, then, she asks, is her baby being transferred for special care? A mother may also feel guilty for not
providing well for her infant in the last few weeks of pregnancy. Make sure a woman spends enough
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time with her newborn to assure herself that although birth did not occur at the predicted time, the
baby should do well with appropriate interventions to control possible hypoglycemia or meconium
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aspiration.
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 All post-term infants need follow-up care until at least school age to track their
developmental abilities. The lack of nutrients and oxygen in utero may have left them with
neurologic symptoms that will not become apparent until they attempt fine-motor tasks.
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 TREATMENT
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Testing may be done for a post-term pregnancy to check fetal well-being and identify problems.
Tests often include ultrasound, nonstress testing (how the fetal heart rate responds to fetal activity),
and estimation of the amniotic fluid volume.
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The decision to induce labor for post-term pregnancy depends on many factors. During labor,
the fetal heart rate may be monitored with an electronic monitor to help identify changes in the heart
rate due to low oxygenation. Changes in a baby's condition may require a cesarean delivery.

Special care of the postmature baby may include:

 Checking for respiratory problems related to meconium (baby's first bowel movement)
aspiration.

 Blood tests for hypoglycemia (low blood sugar).

  NURSING DIAGNOSIS:
 Hypothermia
 Altered nutrition: less than body requirement
 Impaired gas exchange in the lungs & at the cellular level

TOPIC 3. SMALL FOR GESTATIONAL AGE

An infant is Small for Gestational Age (SGA) if the birth weight is below the 10th percentile on an
intrauterine growth curve for that age. SGA infants may be born preterm (before week 38 of gestation),

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term (between weeks 38 and 42), or post-term (past 42 weeks). SGA infants are small for their age
because they have experienced intrauterine growth restriction (IUGR) or failed to grow at the expected

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rate in utero (Rahimian & Varner, 2007). This characteristic makes them distinctly different from infants
whose weight is low but who are average for gestational age.

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 ETIOLOGY:

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A woman’s nutrition during pregnancy plays a major role in fetal growth, so lack of adequate
nutrition may be a major contributor to IUGR. Pregnant adolescents have a high incidence of SGA
infants. Because adolescents must meet their own nutritional and growth needs, needs of a growing
fetus can be compromised.
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In other instances, the placental supply of nutrients is adequate but an infant cannot use them
because the infant has contracted an intrauterine infection such as rubella or toxoplasmosis or has a
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chromosomal abnormality.
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 ASSESSMENT
 APPEARANCE
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Generally, an infant who suffers nutritional deprivation early in pregnancy, when fetal growth
consists primarily of an increase in the number of body cells, is below average in weight, length, and
head circumference.
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The child may have a small liver, which can cause difficulty regulating glucose, protein, and
bilirubin levels after birth. The infant also may have poor skin turgor and generally appear to have a
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large head because the rest of the body is so small. Skull sutures may be widely separated from lack of
normal bone growth. Hair is dull and lusterless. The abdomen may be sunken. The umbilical cord often
appears dry and may be stained yellow.
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 The SGA infant needs careful assessment for possible congenital anomalies occurring as a result
of the poor nutritional intrauterine environment.
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 LABORATORY FINDINGS

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Blood studies at birth usually show a high hematocrit level (less than normal amounts of plasma
in proportion to red blood cells are present because of a lack of fluid in utero) and an increase in the
total number of red blood cells (polycythemia). The increase in red blood cells occurs because anoxia
during intrauterine life stimulates the development of red blood cells. The polycythemia that results
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causes increased blood viscosity, a condition that puts extra work on the infant’s heart because it is
more difficult to effectively circulate thick blood. As a consequence, acrocyanosis (blueness of the hands
and feet) may be prolonged and persistently more marked than usual. If the polycythemia is extreme,
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vessels may actually become blocked and thrombus formation can result.
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 MANAGEMENT
An SGA infant needs adequate stimulation during the infant period to reach normal growth and
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developmental milestones. Encourage parents to provide toys suitable for their child’s chronologic age,
not physical size. Because an infant tire easily in the first few weeks of life, urge them to space play
periods with rest periods or hypoglycemia or apnea can occur. All infants with IUGR need continued
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follow-up after hospital discharge as they may have neurologic deficits that will interfere with learning
at school age (Leitner et al., 2007).
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 NURSING DIAGNOSIS:
 Risk for impaired gas exchange
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 Risk for ineffective thermoregulation & cold stress

 Risk for injury to tissues
 Altered nutrition: less than body requirements
 Risk for altered parenting

TOPIC 4. LARGE FOR GESTATIONAL AGE

An infant is LGA (also termed macrosomia) if the birth weight is above the 90th percentile on an
intrauterine growth chart for that gestational age. Such a baby appears deceptively healthy at birth
because of the weight, but a gestational age examination will reveal immature development. It is
important that LGA infants be identified immediately so that they can be given care appropriate to their
gestational age rather than being treated as term newborns (Lawrence, 2007).

 ETIOLOGY:
Infants who are LGA have been subjected to an overproduction of growth hormone in utero.
This happens most often to infants of women with diabetes mellitus or women who are obese (Strehlow
et al., 2007). Extreme macrosomia occurs in fetuses of diabetic women whose symptoms are poorly
controlled, because these fetuses are exposed to high glucose levels. Multiparous women are also prone

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to have large babies because with each succeeding pregnancy, babies tend to grow larger. Other
conditions associated with LGA infants include transposition of the great vessels, Beckwith syndrome (a

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rare condition characterized by overgrowth), and congenital anomalies such as omphalocele.

 ASSESSMENT

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A fetus is suspected of being LGA when a woman’s uterus is unusually large for the date of

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pregnancy. Abdominal size can be deceptive, however—because a fetus lies in a flexed fetal position, he
or she does not occupy significantly more space at 10 lb than at 7 lb. If a fetus does seem to be growing
at an abnormally rapid rate, a sonogram can confirm the suspicion. A nonstress test to assess the
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placenta’s ability to sustain a large fetus during labor may be performed. To see if an LGA fetus is
mature, lung maturity may be assessed by amniocentesis. If an infant’s large size was not detected
during pregnancy, it may be first recognized during labor when the baby cannot descend through the
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pelvic rim. If this happens, cesarean birth may be necessary to avoid shoulder dystocia (the wide fetal
shoulders cannot pass through the outlet of the pelvis).
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 APPEARANCE
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At birth, LGA infants may show immature reflexes and low scores on gestational age
examinations in relation to their size. They may have extensive bruising or a birth injury such as a broken
clavicle or Erb-Duchenne paralysis from trauma to the cervical nerves if they were born vaginally (see
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Chapter 51). Because the head is large, it may have been exposed to more than the usual amount of
pressure during birth, causing a prominent caput succedaneum, cephalhematoma, or molding. An LGA
newborn requires the same cautious care necessary for a preterm infant.
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 CARDIOVASCULAR DYSFUNCTION
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Observe LGA infants closely for signs of hyperbilirubinemia (increased serum bilirubin level),
which may result from absorption of blood from bruising and polycythemia. Polycythemia has been
caused by an infant’s system attempting to fully oxygenate all body tissues. This effort puts extra stress
on the heart, so the heart rate of LGA infants should be carefully observed.

 HYPOGLYCEMIA
LGA infants also need to be carefully assessed for hypoglycemia in the early hours of life
because infants require large amounts of nutritional stores to sustain their weight. If the mother had
diabetes that was poorly controlled, the infant will have had an increased blood glucose level in utero
causing the infant to produce elevated levels of insulin. After birth, these increased insulin levels will
continue for up to 24 hours of life, possibly causing rebound hypoglycemia.

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 MANAGEMENT:
An LGA infant needs the same developmental care as all infants. Singing or talking to the baby,
stroking the child’s back, and rocking the baby are all important for the large infant’s development.
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Encourage parents to treat their baby as a fragile newborn who needs warm nurturing of this type, not
as a tough big infant who has grown past that stage. Also remind parents an infant’s birth weight is not a
correlation of the child’s projected adult size. Otherwise, parents may fear their infant may grow to be a
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larger-than usual adult.
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 Nursing Diagnoses:
 Altered nutrition: less than body requirements
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 Impaired gas exchange

 Ineffective family coping: compromise
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KEY POINTS
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PREMATURE
POSTMATURE
(SGA) SMALL FOR GESTATIONAL AGE
(LGA) LARGE FOR GESTATIONAL AGE
(IUGR) INTRAUTERINE GROWTH
RESTRICTION
MACROSOMIA
HYPOGLYCEMIA
POST TEST

A link will be sent by the instructor

REFERENCES

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Pillitteri, A. (2006). Maternal and child health nursing. Phildadelphia, PA.:
Lippincott Williams and Wilkins.

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