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Maternal Newborn Nursing

25.4 Preterm Newborn

Maternal Newborn Nursing25.4 Preterm Newborn

Learning Objectives

By the end of this section, you will be able to:

  • Define preterm, extremely preterm, and late preterm, their incidence and the maternal risk factors that increase the likelihood of premature delivery
  • Identify common conditions in the preterm infant
  • Identify necessary nursing interventions and apply them to the care of the preterm infant

A newborn born before the start of the 37th week of gestation is preterm and is at risk for significant morbidity. As medical care has advanced, the survival of preterm infants has increased, and the age at which preterm infants can survive birth has decreased.

Preterm Birth and Maternal Risk Factors

Not all infants born prematurely face equal risks. The subcategories of prematurity are

  • late preterm, born between 34 and 36 completed weeks of pregnancy;
  • moderately preterm, born between 32 and 34 weeks of pregnancy;
  • very preterm, born at less than 32 weeks of pregnancy; and
  • extremely preterm, born at or before 28 weeks of pregnancy (Mayo Foundation for Medical Education and Research [MFMER], 2021).

All premature infants (sometimes called preemies) are at risk for respiratory difficulties called respiratory distress syndrome (RDS) due to immature lungs. In addition, thermoregulation in the newborn relies on brown fat and glycogen availability in the liver, and these are not fully developed until the end of the third trimester. All major health problems in the preterm infant relate to immature body systems.

The birthing parent can have risk factors, modifiable and nonmodifiable, that increase the chances of premature delivery. These factors are summarized in (Table 25.6).

Types of Risk Factors Risk Factors
Demographic risk factors
  • Ethnicity, especially non-Hispanic Black infants, Alaskan native and American Indian infants
  • Under 18 or over 35 years of age
Social risk factors
  • Late or no prenatal care
  • Tobacco use
  • Alcohol use
  • Illegal drug use
  • Domestic violence, including physical, sexual, or emotional abuse
  • Lack of social support
  • Stress
  • Long working hours with long periods of standing
  • Poor nutritional intake
  • Exposure to pollution in the environment
Maternal medical risk factors
  • Being of a lower weight or of a higher weight
  • Diabetes, type 1, type 2, or gestational
  • History of blood clotting problems
  • High blood pressure
  • Uterine abnormalities, e.g., separate uterus
  • Abnormal anatomy of the reproductive organs, e.g., prematurely shortened cervix
  • Urinary tract infections
  • Sexually transmitted infections, e.g., chlamydia, gonorrhea, syphilis
  • Certain vaginal infections, e.g., bacterial vaginosis and trichomoniasis
Maternal obstetric risk factors
  • Pregnancy resulting from in vitro fertilization or the use of assisted reproductive technology
  • Short interval between pregnancies (less than 6 months between a birth and the beginning of the next pregnancy)
  • Pregnant with twins, triplets, or more (multiple gestations)
  • Bleeding from the vagina
  • Placenta previa
  • History of rupture of the uterus, more likely with prior cesarean delivery or removal of a uterine fibroid
Table 25.6 Maternal Risk Factors for Premature Delivery (CDC, 2018)

Prematurity and Its Risks to the Infant

Characteristics of prematurity relate directly to the gestational age of the infant and their health, and nutritional status in the womb. Some broadly noted characteristics include

  • large head with a disproportionately small body;
  • less full or rounded face than a full-term newborn's features due to decreased fat stores;
  • lanugo (Figure 25.14);
  • inability to thermoregulate due to decreased fat stores, resulting in a low body temperature especially immediately after birth in the delivery room;
  • difficult self-management of respirations, resulting in increased work of breathing or respiratory distress; and
  • absent reflexes for sucking and swallowing, directly affecting feeding (MFMER, 2021).
A close-up of human skin showing fine hairs covering the skin’s surface.
Figure 25.14 Lanugo on a Preterm Infant Unborn infants develop lanugo between 16- and 20-weeks’ gestation. These fine hairs cover their entire body except for places without hair follicles. (credit: modification of work “Laguno” by Raumka/Wikimedia Commons, CC0)

In 2022, 1 in 10 births in the United States were premature (Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, 2023). The cause of preterm labor and birth is unknown, but risk factors have been identified that relate to a higher chance of preterm birth. Maternal and pregnancy-related complications increase the risk of preterm delivery. These risk factors include history of premature delivery, multiples, tobacco use and substance misuse, and pregnancies that are less than 18 months apart (see Table 25.6).

Apnea of Prematurity

Immature breathing control in premature infants can result in apnea of prematurity (AOP), a condition in which breathing stops for 15 to 20 seconds or more, shorter if associated with bradycardia or desaturation (Figure 25.15). Almost all neonates born before 28 weeks’ gestation have AOP. In contrast, less than 10 percent of preterm infants born after 34 weeks experience this condition (Erickson et al., 2021).

Diagram showing the concept of not fully developed respiratory control caused by three factors: immature neuromuscular control of upper airway, respiratory centers in the brainstem, and chemoreceptors. The factors lead to outcomes: apnea (obstructive, central, or mixed), which can cause decreased respiratory rate and decreased heart rate; and irregular breathing, which can lead to transient hypoxia.
Figure 25.15 Apnea of Prematurity: Pathophysiology The premature infant’s immature neuromuscular, respiratory, and neurologic systems all affect the action of breathing. The immature control of breathing stems from three areas: neuromuscular, brainstem centers, and peripheral chemoreceptors. These three areas, when ineffective, can result in apnea and periodic breathing that ultimately leads to bradycardia, desaturation, and hypoxia. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Respiratory Distress Syndrome

Respiratory distress syndrome (RDS), once known as hyaline membrane disease, is a common breathing disorder in preterm infants and newborns. When born before the lungs are fully mature, infants are deficient in pulmonary surfactant, in both the quantity and the quality of the surfactant that is in the lungs (Martin, 2023). The lower the gestational age, the higher the incidence of RDS in the neonatal population. White males in the late preterm and term age groups also are at increased risk for RDS.

Signs and Symptoms

The signs and symptoms of RDS all relate to abnormal pulmonary function and hypoxia. The newborn will have tachypnea, nasal flaring, expiratory grunting, and multilevel retractions, as the rib cage is primarily cartilaginous at this age. Cyanosis from right-to-left shunting from both intra- and extrapulmonary shunting may be noted (Martin, 2023).


A chest x-ray is likely to be ordered for any neonate with symptoms of respiratory distress. The x-ray of RDS shows low lung volumes and classic diffuse reticulogranular (“ground glass”) appearance with air bronchograms (Figure 25.16). The symptoms of RDS and the classic image findings on chest x-ray are diagnostic for the syndrome.

An x-ray image of a newborn’s chest with lungs that have a ground-glass appearance. The volume of the lungs do not fully expand to the chest wall. Air-filled bronchi are also visible.
Figure 25.16 Respiratory Distress Syndrome (RDS) This is a chest x-ray of an infant with classic ground glass or hazy appearance of lungs affected by RDS. The lungs should be black rather than light gray. (credit: “X-ray of infant respiratory distress syndrome (IRDS)” by Mikael Häggström, M.D./Wikimedia Commons, CC0)

Nursing Management

RDS usually worsens over the first 2 to 3 days of life, with increased respiratory distress, and then typically with medical intervention gets better as the newborn moves past day 3. The improvement is due to increased production of endogenous surfactant, allowing the immature lungs to better exchange gases. Symptoms are usually gone by 1 week of life. Treatment with antenatal steroids, exogenous surfactant, caffeine, and/or continuous positive airway pressure improves lung function and decreases the clinical course for the patient (Martin, 2023).

The nurse's role is supportive throughout the treatment: administration of medications, frequent laboratory studies focused on oxygenation and ventilation, and frequent and ongoing assessment of the respiratory system to know if therapies are having the desired effect. Much of the treatment and many of the interventions only shorten the course rather than cure any underlying disease process. Educating the parents at the bedside and assisting them in finding ways to be a parent in a hospital setting are nursing interventions.

Meconium Aspiration Syndrome

Respiratory distress in a newborn delivered with meconium-stained amniotic fluid (MSAF) with no other underlying reason for respiratory distress is called meconium aspiration syndrome (MAS). The incidence of MAS in the United States is variable, affecting from 0.1 to 0.4 percent of births (Garcia-Prats, 2019).

Signs and Symptoms

Meconium-stained amniotic fluid can be visible at delivery or cause staining to the newborn’s vernix, umbilical cord, and nails. The newborn can present with perinatal asphyxia, in which the infant has neurologic and/or respiratory depression at birth. These newborns are frequently both postterm, born after 42 weeks, and small for gestational age.

Respiratory symptoms include respiratory distress with tachypnea and cyanosis. The newborn will have a barrel-shaped chest with increased anterior-posterior diameter as the lungs are hyperinflated. In severe cases, this condition can lead to pneumothorax or pneumomediastinum, where air moves into the thoracic space or within the mediastinum. Ultimately, this can all lead to respiratory failure.


Chest radiography initially shows streaky, linear densities much like those found in transient tachypnea of the newborn. Over time, hyperinflation of the lungs with a flattened diaphragm becomes evident. An echocardiogram is done to rule out congenital cardiac disease and persistent pulmonary hypertension. To rule out pneumonia, which can present much like MAS, blood cultures and sputum or tracheal cultures are collected. Diagnosis of MAS is made if a newborn has respiratory distress at birth with no underlying reason other than evidence of meconium-stained amniotic fluid or a chest x-ray with all the classic features of MAS (Garcia-Prats, 2019).

Nursing Management

Prevention is the best management for this syndrome; but when prevention fails, treatment includes caring for the infant with the same algorithm used for any newborn with respiratory distress. Inadequate respiratory effort resulting in gasping, increased work of breathing, and decreased oxygenation is treated with respiratory support, which includes tracheal intubation. If obstruction is suspected, tracheal suction may be beneficial. Airway obstruction is an increased risk for neonates who have been delivered through MSAF (Garcia-Prats, 2023).

Guidelines from the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) recommend against routine intrapartum nasopharyngeal suctioning when meconium is suspected (Garcia-Prats, 2023; Vain et al., 2004). Around 30 percent of newborns with MAS require mechanical ventilation because of respiratory failure (Singh et al., 2009). Surfactant is not routinely administered to newborns with MAS. However, if the patient is mechanically ventilated and requires greater than 50 percent concentration of oxygen in the gas mixture, or fraction of inspired oxygen (FiO2) along with elevated ventilator settings, surfactant potentially decreases poor oxygen absorption and pulmonary vascular resistance. Ultimately, that may decrease the need for treatment with inhaled nitric oxide (iNO) or ECMO (El Shahed et al., 2014).

Persistent Pulmonary Hypertension of the Newborn

If the pulmonary vascular resistance stays high after birth, the newborn is diagnosed with persistent pulmonary hypertension of the newborn (PPHN). The high right-sided pressures lead to right-to-left shunting of unoxygenated blood through residual fetal circulatory pathways, such as the patent ductus arteriosus (PDA) or patent foramen ovale (PFO). This results in low oxygen saturations that do not respond to treatment with oxygen or respiratory support (Stark & Eichenwald, 2022).

There are a few potential causes of PPHN. The highest mortality risk arises from underdevelopment of the pulmonary vasculature. This occurs with congenital diaphragmatic hernia (CDH), congenital pulmonary malformation, renal agenesis, or obstructive uropathy leading to oligohydramnios and fetal growth restriction (Mandell et al., 2020). Maldevelopment of the pulmonary vasculature is when the anatomy is structurally normal in the newborn, but the pulmonary vascular bed needs 1 to 2 weeks to allow for remodeling in the extrauterine environment. After remodeling occurs, the pulmonary vascular resistance drops as expected after birth (Murphy et al., 1981). The most common findings concurrent with maldevelopment of the pulmonary vasculature are MAS, meconium staining, and postterm gestational age. Maladaptation of the pulmonary vasculature also has normal anatomy, but active vasoconstriction starts during the prenatal period, related to perinatal depressions or pulmonary parenchymal diseases or bacterial infections, particularly group B streptococcus. Vasoconstriction continues after birth (Murphy et al., 1981). Risk factors for PPHN, both maternal and prenatal, include

  • maternal diabetes, gestational or preexisting;
  • maternal obesity;
  • advanced maternal age;
  • in utero exposure to selective serotonin reuptake inhibitors (SSRIs);
  • Black race;
  • meconium-stained amniotic fluid;
  • large or small for gestational age; and
  • prolonged premature rupture of the membranes (Stark & Eichenwald, 2022).

Treating the underlying reason for PPHN is the goal. Immediate resuscitation for respiratory failure, hypoxemia, and cardiovascular instability is the first step of immediate care, followed by determining the underlying cause.

Bronchopulmonary Dysplasia

One common preterm respiratory disease with significant mortality and morbidity is bronchopulmonary dysplasia (BPD), also known as neonatal chronic lung disease (CLD) (Eichenwald & Stark, 2023). BPD has a multifactorial etiology that is caused by underdeveloped lungs and injury from antenatal and/or postnatal events. Maternal smoking or intrauterine growth restriction affects lung development, as does postnatal mechanical ventilation, oxygen toxicity, or infection causing lung damage (Jensen & Schmidt, 2014).

Signs and Symptoms

BPD can present with variable signs and symptoms, although most affected infants are tachypneic and have some degree of pulmonary edema and/or atelectasis resulting in baseline retractions and rales on auscultation. An expiratory wheeze can be heard due to the classic airway narrowing (Jensen & Schmidt, 2014). On chest x-ray, the lung fields will have diffuse haziness and coarse interstitial patterns. Over time, severe BPD will result in hyperinflation of the lungs. BPD ranges in severity: Mild presentations require only oxygen; severe symptoms such as hypoxemia and hypercapnia require ventilation. Mobile cartilage in the airways, called bronchomalacia, can cause airway collapse during exhalation and is commonly found as a comorbidity with BPD (Jensen & Schmidt, 2014). Bronchomalacia can significantly worsen the course of the disease and the outcome (Hysinger et al., 2017).


A clinical diagnosis of BPD is made based on the premature infant, at 36 weeks’ gestation, requiring oxygen. An oxygen reduction test is performed to define the need for oxygen supplementation to confirm the diagnosis. A positive test for the diagnosis of BPD is an oxygen saturation below 90 percent within 60 minutes of removing oxygen from the neonate (Jensen & Schmidt, 2014).

Nursing Management

Management of the neonate with BPD is focused on respiratory support. As the infant grows, their airways become less mobile, and collapse is less likely. Most will have gradual improvement over the first 2 to 4 months of life. Infants with more severe presentations of BPD may require inhaled corticosteroids and beta agonists through infancy. They may also require a prolonged course of mechanical ventilation, which can require a tracheostomy, and are at risk of developing pulmonary hypertension and cor pulmonale (Jensen & Schmidt, 2014).

Neonatal Sepsis

Neonatal sepsis results from a bacterial, fungal, or viral infection that affects the whole body rather than one area or system. In the neonatal period, sepsis can cause severe morbidity and mortality. The underlying infection can come from the intrauterine environment or the NICU environment. Early-onset neonatal sepsis is when the infection occurs within 3 to 7 days of birth. Late-onset neonatal sepsis occurs either from day 4 through day 30 of life or after the first week of life up to the first month of life. Very late-onset sepsis occurs only in infants who have been in the NICU beyond the first month of life.

Multiple factors of both the newborn and the birthing parent put the newborn at higher risk of neonatal sepsis. These factors are summarized in (Table 25.7).

Category of Risk Risk Factors
Newborn Premature birth
Low birth weight
Fetal distress
Low Apgar score
Birthing parent Chorioamnionitis
Premature rupture of membranes
Intrapartum maternal fever
Positive GBS
Medical treatment Requiring resuscitation
Frequent blood draws in NICU
Requiring intubation and mechanical ventilation
Long-term parenteral nutrition
Surgical interventions
Table 25.7 Risk Factors for Acquiring Neonatal Sepsis

Signs and Symptoms

The presentation of the infection can be subclinical without notable symptoms or be severe, affecting either one body system or the body as a whole. Signs of infection can present with the respiratory system and include increased work of breathing, apnea, cyanosis, and tachypnea. Other symptoms can be cardiovascular with heart rate changes, tachycardia or bradycardia, poor peripheral circulation, hypotension, and extended capillary refill. Generalized gastrointestinal symptoms may also present, including feeding intolerance, vomiting, diarrhea, abdominal distention along with jaundice, petechiae, or purpura. The newborn may also be inactive, irritable, and have poor thermoregulation (Odabasi & Bulbul, 2020). Neonates are more likely to have hypothermia rather than fevers, given their lack of ability to shiver.


A positive culture, whether blood, urine, or cerebrospinal, pleural, peritoneal, or synovial fluid, is the gold standard for diagnosing neonatal sepsis. The minimum amount of blood that allows a culture to grow is 0.5 to 1 mL of fluid. For blood cultures to determine sepsis, blood is collected prior to antibiotic administration, and two samples from two different sites are sent for laboratory evaluation. Cerebrospinal fluid culture is recommended in newborns or infants under 21 days of age who have had a positive blood culture and are suspected to have meningitis. Urine culture is not necessary, but neonates who require intubation should have a tracheal aspirate sent to culture. The complete blood count (CBC) gives measurements for the number of white blood cells (WBC), red blood cells (RBC) to hematocrit (HCT) ratio, and the number of platelets (Plt). This information, with a peripheral smear, which results in the number of neutrophils or immature WBCs, can give some indication of the newborn’s infectious status. CBCs collected within 72 hours of birth reflect more of the birthing parent’s system rather than serving as a biomarker in neonatal sepsis (Odabasi & Bulbul, 2020).

Nursing Management

Antibiotics are started as soon as sepsis is suspected in an infant. These drugs are a high priority and are ordered stat with an expectation of having them given as soon as possible, administered intravenously. Ampicillin and an aminoglycoside are typically given to cover the most common causative bacteria in newborns, Group B streptococcus, Escherichia coli (E. coli), and Listeria monocytogenes (L. monocytogenes) (Polin, 2012; Singh et al., 2022). If the neonate is at risk of having acquired a nosocomial infection, they are treated with vancomycin and an aminoglycoside. Aminoglycosides have poor central nervous system (CNS) penetration, and a third-generation cephalosporin would need to be added for CNS treatment if meningitis is suspected or confirmed (Singh et al., 2022). Listeria monocytogenes, commonly called listeria, is a gram-positive bacterium that can infect newborn infants from maternal contamination. Penicillin is included in antibiotic treatment specifically for this bacterium, which, though no longer common, is still deadly.

Nurses are relied on to collect and support collection of culture fluids and to administer the antibiotic regimen while monitoring vital signs and intravenous access for safe administration and tolerance of treatment. Neonates treated with antibiotics show improvement within the first day or two and are usually culture negative by day 3. Intravenous antibiotic therapy correlates to the infectious agent and usually is ongoing for 7 to 10 days. Central nervous system involvement can add to the length of antibiotic treatment. The more preterm the neonate, the higher the mortality rate from sepsis (Singh et al., 2022).

Perinatal Hypoxic-Ischemic Brain Injury

Death of tissue due to lack of oxygen over a period of time, called hypoxic ischemia (HI), is a brain injury that results in varying presentations of brain damage. Immature brain tissue is at higher risk for HI and responds to the injury with greater sensitivity than mature brain tissue. Hypoxic-ischemic brain damage (HIBD) is a common nervous system disease in neonates whether they are full-term or premature. HIBD is one of the primary causes of neonatal death. Infants with HIBD may later have cerebral palsy, intellectual disabilities, developmental delays, and learning difficulties, along with other life-altering sequelae. When HI occurs in a term infant, the damage occurs in the brain’s gray matter; in a preterm infant, the white matter is affected (Yang et al., 2020).

Signs and Symptoms

Signs of hypoxic-ischemic injury can include decreased activity, but some infants may react more to stimulation than an infant without hypoxic injury. Newborn reflexes may be absent, with abnormal movements indicating seizure. The infant may demonstrate abnormal muscle tone (increased or decreased) and respiratory difficulties. In hypoxic-ischemic encephalopathy, or HIE—the result of brain tissue not receiving enough oxygenated blood over a period of time—signs and symptoms may not present immediately after labor and delivery but rather show up later, in the first days, weeks, or months of life (The General Hospital Corporation, 2022).


A newborn suspected of having a hypoxic-ischemic injury from birth is assessed using a modified Sarnat examination. The Sarnat tool has six categories, each scored as mild, moderate, or severe. A newborn is diagnosed with HIBD if three of the six categories are scored as moderate. Seizure in the first few hours after birth is unlikely but becomes more common over time. An electroencephalogram (EEG) to monitor for subclinical seizures is necessary for a newborn being treated for HI injury.

Nursing Management

Therapeutic hypothermia (also known as cooling) is the only therapy shown to reduce the risk of death or disability in newborns with moderate to severe hypoxic-ischemic encephalopathy (HIE) (Bonifacio & Hutson, 2021). Treatment is started within the first 6 hours from birth. Therapeutic hypothermia reduces the risk of death and moderate to severe neurologic impairment at 2 years of age and by school age (Bonifacio & Hutson, 2021). Current research suggests that alternative or adjunct therapies could improve outcomes for neonates with HIE. These potential therapies include stem cell transplantation, erythropoietin administration, and magnesium sulfate administration (Yang et al., 2020).

Intraventricular Hemorrhage

Bleeding in the spaces (ventricles) and fluid-filled areas of the brain, called intraventricular hemorrhage (IVH), is a serious complication of very preterm and extremely preterm infants. Immature brain blood vessels are fragile and easily break, bleeding into the cavities nearby (Gilard et al., 2020; The Johns Hopkins University, 2023). Risk factors beyond prematurity include multiples, difficult delivery, inflammation, and respiratory or cardiopulmonary instability (Gilard et al., 2020).

Signs and Symptoms

No signs and symptoms of IVH may be present. Symptoms that may be present are apnea, decreased muscle tone and reflexes, excessive sleep, lethargy, and a weak suck.


Head ultrasound (HUS) is recommended for any premature infant born before 30 weeks of gestation. The imaging is done once in the first 2 weeks of life and again close to the corrected gestational age of 40 weeks. A HUS is diagnostic for IVH. A head CT is the diagnostic imaging recommendation for newborns who are term but have symptoms or risk factors that point to IVH having occurred. These factors include a difficult birth followed by low blood count or signs and symptoms of increased intracranial pressure (The Johns Hopkins University, 2023).

Nursing Management

No treatment exists to stop intraventricular bleeding. The degree of bleeding determines the amount and type of support needed for the newborn with IVH. If blood loss results in anemia, a transfusion is given to support the neonate. If hydrocephalus, enlargement of the skull as a result of increased intercranial pressure, develops, surgical placement of a shunt or drain to relieve pressure in the brain may be needed (The John Hopkins University, 2022). The amount of damage and support required determines the ultimate prognosis for the neonate with IVH.

Intracranial Hemorrhage

Intracranial hemorrhage is bleeding inside the brain labeled by where it is found. One type is subdural hemorrhage, bleeding within the subdural space. Tearing of the blood vessels between the cerebrum and cerebellum is the most common cause. This type of hemorrhage has become rare as obstetric medicine has advanced. Bleeding within the subarachnoid space, called subarachnoid hemorrhage, occurs in full-term infants as a result of trauma and is the most common type of intracranial hemorrhage. Bleeding in the cerebellar region, called intracerebellar hemorrhage, is usually diagnosed postmortem in a preterm infant who sustained significant skull compression during an abrupt precipitous delivery. It may also be found in full-term infants with a difficult delivery (Tan et al., 2018).

All these hemorrhages are diagnosed with the same imaging tools used for IVH, along with a head MRI. They are all treated with the same supportive management. The severity of the bleed determines the infant’s prognosis.

Neonatal Seizures

Seizures are the most frequent symptoms of an abnormality of central nervous system (CNS) dysfunction in the neonate. The immature newborn brain is more susceptible to seizures than a brain in any other period of development (Spoto et al., 2021). The cause for seizures can be connected to an acute event like hypoxic-ischemic encephalopathy or intracranial hemorrhage, stroke, or infection. Alternatively, seizures may result from an underlying disease process such as a genetic, metabolic, or structural condition; but many times, direct causation is difficult to determine.

Signs and Symptoms

Obvious signs of seizure in the neonate include clonic movements, or hypertonia, or fine movements of the tongue or eyes, but these are not always present. Subtle signs and symptoms would include lip smacking and twitching of one area such as an eye or a hand. Many seizure events in neonates are clinically silent, without any outward symptoms. This makes the use of the EEG very important in finding these asymptomatic seizures (Spoto et al., 2021).


The gold standard for diagnosing seizures in a neonate is video-electroencephalogram (EEG) recording. Seizures in the neonatal period have a focal onset, but they can be associated with nonmotor or motor symptoms. Motor symptoms may look like epileptic spasms or myoclonic movement. Nonmotor symptoms include autonomic or behavioral responses such as apnea or sleepiness (Spoto et al., 2021).

Nursing Management

Early identification of seizures followed by early treatment offers the best chance of avoiding long-term consequences like neurodevelopmental delays. Antiepileptic drugs (AED) are the first line of treatment for neonatal seizures; however, none currently has a perfect response rate, and some drugs have potentially serious side effects.

Levetiracetam (Keppra) has increased in popularity as a first-line choice in treating neonatal seizures. This antiepileptic drug has been available on the market since 2000. It has few side effects, does not require frequent lab draws for drug levels, and does not interact unfavorably with many other medications. When a neonate has a drug-resistant seizure, no AED is effective in stopping the recurrence of seizures. In such cases, corticosteroid therapy has been used (Spoto et al., 2021).

Clinical Safety and Procedures (QSEN)

Prevention of Nosocomial Infections in the NICU

Nosocomial infections (NI) in infants are associated with long stays in the hospital, resulting in increased incidence of delayed neurodevelopmental outcome and increased rates of mortality. In the past 10 years, NICUs have increased prevention strategies, ultimately decreasing NI rates overall (Jansen et al., 2021).

The best outcomes—zero NIs—have been accomplished with the use of quality improvement collaboratives and benchmarking while relying on prevention rather than treatment (Jansen et al., 2021).

General Prevention Strategies

  1. Hand hygiene. Use the nudge to encourage handwashing. An example of the nudge would be a sign above the sink as a reminder to wash your hands.
  2. Human milk feeding. Offer donor milk, and encourage pumping with the use of lactation consultants.
  3. Antibiotic stewardship programs. Include pharmacists on the interdisciplinary team.
  4. Single-room care. Focus on the physical layout and functionality of the patient’s environment. Hospital designs are shifting away from open-bay models to single-room units.
  5. Probiotics. Administer enteral probiotic supplementation (Jansen et al., 2021).

Necrotizing Enterocolitis

Neonates are at risk for necrotizing enterocolitis (NEC), an ischemic necrosis of the intestinal mucosa. It is associated with inflammation, bacteria that create enteric gas, and dissection of the bowel wall, along with portal venous system free air. An exact cause is unknown when there are no other underlying comorbidities. Diagnosed early and treated quickly, the condition can have a positive clinical outcome; but overall, it is a high mortality and morbidity disease of the neonate (Kim, 2020). NEC occurs in almost 10 percent of premature infants but is rare in full-term neonates (Children’s Hospital of Los Angeles, 2023).

Signs and Symptoms

Most preterm infants who develop NEC have no preceding symptoms and are feeding well and growing. The most frequent sign of NEC is an abrupt change in feeding tolerance with abdominal distention, abdominal tenderness, vomiting (particularly bilious vomiting, which is dark green), diarrhea, and rectal bleeding. Nonspecific symptoms of NEC are apnea, respiratory failure, lethargy, and temperature instability. The most common symptoms of infection in infants are apnea, respiratory failure, and temperature instability. The commonality of these symptoms is reflected with the 20 percent to 30 percent of infants having bacteremia concurrently with NEC (Kim, 2020).


NEC is clinically diagnosed from the symptoms presented by the infant—abdominal distention, bilious vomiting, and rectal bleeding with bloody stool—along with an x-ray of the abdomen showing pneumatosis intestinalis, intramural gas in the intestines (Figure 25.17). The only definitive diagnosis is made with a surgical sample or a postmortem assessment with tissue that shows histologic findings of intestinal inflammation, infarction, and necrosis.

An x-ray image of an infant shows gas patterns within the intestinal wall characterized by dark, circular areas against the denser background of the abdomen. The patterns are irregularly distributed throughout the intestine.
Figure 25.17 x-ray of an Infant with NEC This photo shows an abdominal film with pneumatosis intestinalis, a radiologic sign seen in patients with necrotizing enterocolitis (NEC). The abdominal x-ray shows the intramural air bubbles that occur in the bowel wall from gas produced by bacteria in the intestinal wall lining. Note the bubbly lucencies filling the abdominal cavity. (credit: “Pneumoperitoneum and Pneumatosis Intestinalis” by Sheng Q, Lv Z, Xu W, Liu J, Wu Y, Shi J, Xi Z. /Wolters Kluwer Health, CC BY 4.0)

Nursing Management

When NEC is suspected, immediate supportive care is initiated. The infant is made NPO, and supportive parenteral nutrition such as TPN is started. Empiric antibiotic therapy is begun. Frequent serial examinations and serial abdominal x-rays are used to monitor the evolution of NEC. The antibiotics are intended to limit the progression of the disease, while close monitoring follows the severity of the disease (Kim, 2020). If severe, surgical intervention may be required.


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