Which would the nurse do to most accurately confirm that the newborn may be at risk for withdrawal?

The first few months of life, known as the newborn phase, are vital for both the child’s physical adaptation to extrauterine life as the neonate begins to breathe, suckle, swallow, digest, and eliminate naturally. Throughout their first year, infants continue to mature quickly, learning new skills as they engage with their environment.

Physical milestones include:

• Weight gain
• Eyesight
• Hearing
• Smell
• Taste
• Touch
• Reflexes
• Motor development

The first week of life is the most fragile. 75% of neonatal deaths occur during this time. Newborn mortality is often related to preterm birth, intrapartum-related issues (birth asphyxia or absence of breathing at birth), infections, and birth abnormalities.

The Nursing Process

Nurses are expected to evaluate and monitor the neonate as part of a newborn assessment. This includes an Apgar score, which is a rapid assessment of respiratory and heart rate, muscle tone, reflexes, and color. Later measurements will include height and weight and lab tests. 

Nurses are also a source of education and support to new parents as they transition into parenthood. The nurse assists parents in feeding, bathing, and learning to respond to the newborn’s cues.

Nursing Care Plans Related to Newborn Assessment and Care

Risk for Impaired Gas Exchange

Risk for impaired gas exchange can be caused by delayed or poor adaptation to life outside the uterus. It may also be caused by pre-existing conditions like congenital defects, or acquired disorders like lung infections that develop before or after delivery.

Nursing Diagnosis: Risk for Impaired Gas Exchange

Related to:

• Low lung function and compliance
• Significant increased metabolic rate
• The tendency for reduced functional residual capacity (FRC)
• Increased resistance by excess production of mucus
• Cold stress

Expected outcomes:

• Patient will be able to maintain ABGs within normal limits.
• Patient will be able to maintain oxygen saturation within normal limits. 
• Patient will remain absent of nasal flaring and chest wall retractions.

Risk for Impaired Gas Exchange Assessment

1. Assess the client’s respiratory status.
The respiratory assessment reflects the effectiveness of alveolar ventilation. Low Pao2 levels may indicate the need for ventilatory support.

2. Note the presence of symptoms of labored breathing.
Observe for nasal flaring, grunting, chest wall retractions, and cyanosis. These symptoms may suggest increased oxygen usage and energy expenditures.

3. Review the results of hemoglobin and arterial blood gas (ABG) tests.
ABGs are influenced by the newborn’s respiratory, circulatory, and metabolic processes. Hemoglobin levels show the status of the oxygen-carrying capacity of the blood.

4. Assess the newborn’s caregiver’s knowledge of identifying symptoms of respiratory distress.
The parents/caregiver need to be aware of the infant’s expected behaviors, responses, and activities. Newborn respiratory distress includes tachypnea, nasal flaring, periods of apnea, cyanosis, noisy breathing, grunting, and chest retractions.

Risk for Impaired Gas Exchange Interventions

1. Elevate the head of the bed.
Breathing is easier in an elevated or upright position. This position promotes optimal chest expansion. It is also easier to assess the newborn in this position for any symptoms of respiratory distress.

2. Suction the airway as needed.
A newborn may not be able to clear secretions on their own and may require suctioning if mucus is heard or observed. Measure patient’s pulse oximetry and vital signs to check for the effectiveness of suctioning.

3. Administer oxygen.
Oxygen can be delivered through nasal cannula or face mask to aid in gas exchange.

4. Prepare equipment for emergency ventilation.
Emergency ventilation supplies should always be available at the bedside. Suction catheters and an ET/tracheostomy set must be suitable for the size of an infant in preparation for opening the airway during an emergency.

Risk for Hypothermia

Risk for Hypothermia in a newborn is related to a high surface area to volume ratio. This ratio is higher in low-birth-weight newborns, causing rapid heat loss and hypothermia. It can also be caused by the transition from a warm environment inside the uterus to one that is considerably cooler.

Nursing Diagnosis: Hypothermia

Related to:

• Large surface area compared to mass
• Inadequate insulating subcutaneous fat
• Exhaustible brown fat sources
• Few white fat reserves
• Thin epidermis susceptible to increased heat loss
• Inability to shiver
• Infectious process
• Impaired thermoregulation
• Environmental concerns
• Cesarean delivery

Expected outcomes:

• Patient will be able to maintain a body temperature within normal limits.
• Parents/caregiver will verbalize the understanding of hypothermia and its prevention.

Risk for Hypothermia Assessment

1. Monitor the newborn’s body temperature.
Accurate temperature measurement is necessary to ensure correct diagnosis and interventions. Newborn temperatures should be measured rectally for the most accurate assessment. Educate the parents/caretakers on how to properly check the temperature. A temperature below 97.7 F (36.5 C) is below normal.

2. Assess risk factors.
Low-birth weight, prematurity, and poor thermoregulation due to sepsis or drug withdrawal can increase the risk of hypothermia.

3. Monitor for cold stress.
Cold stress results in severe metabolic and physiological problems. Oxygen consumption and calorie expenditure occur in the newborn’s attempt to produce heat. If this is prolonged it can impair growth.

Risk for Hypothermia Interventions

1. Keep the newborn dry and tightly wrapped in a blanket.
The newborn may lose heat quickly as a result of wet skin. The baby should be quickly dried and swaddled.

2. Provide heat loss barriers.
Newborns, especially preterm and/or low-birth-weight infants, require barriers to prevent heat loss. Vigorous rewarming while regularly monitoring temperature is needed. Blankets, isolettes, and radiant warmers can be utilized. Encourage skin-to-skin contact of the newborn with the mother. Studies have shown that this helps minimize the risk of hypothermia.

3. Provide a warm environment.
The newborn has not acquired extra adipose tissue to act as insulation and is not able to shiver to warm the body naturally. Therefore, newborns cannot regulate their temperature. Newborns can lose heat nearly 4 times quicker than an adult. If the room temperature is too low, even healthy, full-term newborns may struggle to stay warm.

4. Provide education to the parents/caregiver.
Newborns struggle to adjust to temperature changes. The nurse may inform parents/caregivers about the dangers of hypothermia and hyperthermia. Explain the importance of a newborn’s thermal protection. Ensure the newborn’s routine care includes the prevention of hypothermia. Demonstrate and supervise activities such as bathing and swaddling.

Risk for Infection

Risk for Infection is related to the increased susceptibility to infection. The newborn’s immune system is immature and can not yet protect against pathogens – at least for the first few months.

Nursing Diagnosis: Risk for Infection

Related to: 

• Inadequate acquired immunity
• Deficiency of neutrophils and specific immunoglobulins
• Environmental exposure
• Broken skin
• Traumatized tissues
• Decreased ciliary action

Expected outcomes:

• Parents/caregiver will verbalize two infection prevention or risk reduction measures.
• Parents/caregiver will demonstrate a protected environment for the newborn.
• Patient will remain free from infection.

Risk for Infection Assessment

1. Assess for contributing factors.
Risk factors for infection include an immature immune system and underlying disease. Newborns are more susceptible to disease and infection because of inadequate immunoglobulin levels (IgA, IgE, and IgD). Prematurity, congenital defects, and maternal complications such as premature rupture of membranes (PROM) or delivery trauma increase the risk of infection.

2. Assess for presence or absence of immunity.
Natural immunity is required to prevent the recurrence of a particular disease. It is developed through the production of antibodies following infection. Certain communicable diseases can be prevented with passive immunization (such as immunoglobulin administration) and active immunization (such as vaccination).

3. Monitor for symptoms of infection.
Poor feeding, trouble breathing, fever, prolonged crying, and irritability are indications of an infection.

Risk for Infection Interventions

1. Ensure strict compliance to infection control and hand hygiene.
Hand washing is the primary protection against healthcare-associated illnesses. When providing care and especially with invasive interventions, the nurse must follow strict infection prevention to safeguard the newborn against infection.

2. Encourage breastfeeding.
While a personal choice, mothers who desire to breastfeed should be encouraged and instructed to do so. Breast milk contains natural immunoglobulins necessary to protect newborns against preventable infections.

3. Monitor caregivers and visitors for any existing illnesses.
To prevent exposure and transmission risk, encourage sick guests to avoid contact with the newborn. Caregivers or visitors may wear masks to further prevent the transmission of bacteria or viruses.

4. Provide health teaching about infection control measures.
Educate parents and caregivers to consistently practice infection control measures such as proper hand hygiene. Limit public outings during the first few weeks. Recommend necessary vaccinations. Provide educational materials and demonstrations as necessary.

References and Sources

1. Berman, A., Snyder, S., & Frandsen, G. (2016). Promoting Health from Conception Through Adolescence. In Kozier and Erb’s fundamentals of nursing: Concepts, practice, and process (10th ed., pp. 330-335). Prentice Hall.
2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
3. Gallacher, D. J., Hart, K., & Kotecha, S. (2016). Common respiratory conditions of the newborn. Breathe, 12(1), 30-42. https://doi.org/10.1183/20734735.000716
4. Nettina, S. M. (2019). Pediatric Primary Care. In Lippincott manual of nursing practice (11th ed., pp. 3223-3224). Lippincott-Raven Publishers.
5. Silvestri, L. A., & CNE, A. E. (2019). Care of the Newborn. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 810-826). Saunders.

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