NCP The Preterm Infant

Any infant born prior to completing 37 weeks’ gestation is identified as premature. Thus, the level of development and maturity, and often the degree of complications, varies within this group, dependent on the length of gestation.

NEONATAL ASSESSMENT DATA BASE

Circulation

Apical pulse may be rapid and/or irregular within a normal range (120–160 bpm).
Audible heart murmur may indicate PDA.

Food/Fluid

Weight less than 2500 g (5 lb 8 oz).
Body long, thin, limp with a slight potbelly.
Suck/swallow reflex may be absent/uncoordinated (impacts feeding choices).

Neurosensory

Head size large in relation to body; sutures may be easily movable; fontanels may be large or wide open.
May demonstrate twitching or eye rolling.
Edema of eyelids common; eyes may be fused shut (depends on gestational age).
Reflexes depend on gestational age; rooting well established by 32 weeks’ gestation; coordinated reflexes for sucking, swallowing, and breathing usually established by 32 wk; first component of Moro’s reflex (lateral extension of upper extremities with opening of hands) appears at 28 wk; second two components (anterior flexion and audible cry) appear at 32 wk.
Dubowitz examination indicates gestational age between 24 and 37 wk.
Respiration
Apgar scores may be low.
Respirations may be shallow, irregular; diaphragmatic with intermittent or periodic breathing (40–60/min).
Grunting, nasal flaring, suprasternal or substernal retractions, or varying degrees of cyanosis may be present.
Auscultatory presence of “sandpaper” sound indicates RDS.

Safety

Temperature fluctuates easily.
Cry may be weak.
Face may be bruised; caput succedaneum may be present; labor or delivery may have been precipitous.
Skin reddened or translucent; color may be pink/ruddy, acrocyanotic, or cyanotic/pale.
Lanugo widely distributed over entire body.
Extremities may appear edematous.
Sole creases may or may not be present on all or part of the foot.
Nails may be short.

Sexuality

Female labia minora may be larger than labia majora, with prominent clitoris.
Male testes may not be descended; rugae may be scant or absent on scrotum.

Teaching/Learning

Maternal history may reveal factors that contributed to preterm labor, such as young age; low socioeconomic background; closely spaced pregnancies; multiple gestation; poor nutrition; previous preterm birth; obstetric complication such as abruptio placentae, premature rupture of membranes (PROM), premature dilation of cervix, presence of infection; blood incompatibility associated with erythroblastosis fetalis; or use of prescription, over-the-counter, or street drugs.

DIAGNOSTIC STUDIES

Choice of tests and the expected results depend on presenting problems and secondary complications.
Amniotic Fluid Studies: For lecithin-to-sphingomyelin (L/S) ratio, fetal lung profile, and phosphatidyl glycerol/phosphatidyl inositol may have been performed during pregnancy to assess fetal maturity.
CBC: Decreases in Hb/Hct may be associated with anemia or blood loss. WBC count may be <10,000/mm3>

NURSING PRIORITIES

1. Promote optimal respiratory functioning.
2. Maintain neutral thermal environment.
3. Prevent or reduce risk of potential complications.
4. Maintain homeostasis.
5. Foster development of healthy family unit.

DISCHARGE GOALS

1. Maintaining physiological and behavioral homeostasis with minimal external support.
2. Weight 41/2 lb or greater appropriate to age/condition.
3. Complications prevented/resolving or independently managed.
4. Family identifying and using resources appropriately.
5. Family demonstrates ability to manage infant care.
6. Plan in place to meet needs after discharge.