MARTERNAL CHAPTER 26 NURSING CARE OF A FAMILY
WITH A HIGH-RISK NEWBORN LATEST STUDY GUIDE 2026
During pregnancy, screening birthing parents for risk factors, such as being younger or older than
average maternal age, having concurrent disease conditions such as diabetes or HIV infection,
experiencing pregnancy complications such as placenta previa, or having an at-risk lifestyle such
as one that includes substance use, all of which could lead to illness in a newborn, is essential to
identify infants who may need greater than usual care at birth (Eken et al., 2016). Unfortunately,
not all instances of high-risk situations can be predicted during pregnancy or birth because even
a newborn from an uneventful pregnancy may require specialized care or may develop a problem
over the first few days of life, necessitating intervention. Any newborn, especially one who is
born dysmature (a newborn whose birth weight is inappropriately low for gestational age),
whether preterm, term, or postterm, is at risk for complications at birth or in the first few days of
life. Parents need a thorough explanation of their baby’s health because these problems may
require readmission to the hospital or additional follow-up at home. Because preterm birth in
particular has the potential for leading to high-risk newborns, several Healthy People 2030 goals
directly concern preterm births (Box 26.1).
Being able to predict if a newborn is at high risk allows for advanced preparation so that
specialized, skilled healthcare personnel can be present at the child’s birth to perform necessary
interventions, such as resuscitating a newborn who has difficulty establishing respirations.
Immediate, skilled handling of any problems that occur may help to save the newborn’s life and
prevent future problems, such as neurologic disorders (Wyckoff et al., 2015).
Nursing Process Overview ASSESSMENT
All newborns need to be assessed at birth for obvious congenital anomalies and gestational age
(number of weeks the newborn remained in utero). Both determinations can be done by the
provider who first examines the newborn. The initial assessment is performed under a
prewarmed radiant heat warmer to prevent heat loss. Continuing assessment of the high-risk
newborn involves the use of technology and equipment such as cardiac, apnea, oxygen
saturation, and blood pressure monitoring. Regardless of how many monitors are used, they do
not replace the role of frequent, close, commonsense observations by the nurse who knows the
neonate well from having cared for the newborn consistently over time. The nurse can often
sense changes before a monitor or other equipment begins to put a quantitative measurement on
the change. Carefully evaluate comments made by the parents during healthcare visits, as these
observations similarly need to be taken into consideration during the visit.
NURSING DIAGNOSIS
To establish nursing diagnoses for high-risk neonates, it is important to be aware of the usual
parameters of newborns. Examples of nursing diagnoses that center on the priority areas of care
for all newborns include: Ineffective airway clearance related to the presence of mucus or
amniotic fluid in the airway Ineffective tissue oxygenation related to breathing difficulty
Ineffective thermoregulation related to immature status Fluid volume deficit risk related to
insensible water loss Malnutrition risk, less than body requirements, related to the lack of
strength for effective sucking Infection risk related to lowered immune response because of
prematurity Impaired parenting risk related to illness in newborn at birth Readiness for
developmental care to decrease overstimulation caused by necessary lifesaving procedures
,OUTCOME IDENTIFICATION AND PLANNING
Be certain when establishing expected outcomes that they are consistent with a newborn’s
potential. A goal that implies complete recovery from a major illness, for example, may be
unrealistic for one newborn but completely appropriate for another. Be certain plans of care are
individualized, considering a newborn’s developmental level, as well as physiologic strengths,
weaknesses, and needs. Many families of a high-risk newborn will need support to care for their
neonate at home and, therefore, may need a referral for home healthcare or other resources.
Direct families to helpful websites and other resources as appropriate (see Chapter 20).
IMPLEMENTATION
Interventions for any high-risk newborn are best carried out by a consistent healthcare team and
should focus on conserving the neonate’s energy and providing a neutral thermal environment to
prevent exhaustion and hypothermia. Painful procedures should be kept to a minimum to help
the neonate achieve a sense of comfort and balance. Assisting parents to participate in care such
as bathing or feeding their newborn can help to promote bonding.
OUTCOME EVALUATION
High-risk newborns need long-term follow-up so any consequences of their birth status, such as
minimal neurologic injury, can be identified. Examples of expected outcomes include: The
neonate maintains a patent airway. The neonate demonstrates an ability to suck effectively. The
neonate tolerates procedures without accompanying apnea, bradycardia, or oxygen desaturation.
The neonate demonstrates growth and development appropriate for gestational age (AGA), birth
weight, and condition. The neonate maintains a body temperature of 98.6°F (37.0°C) in an open
crib with one added blanket. The parents visit at least once and make three telephone calls to the
neonatal nursery weekly. The parents demonstrate positive coping skills and behaviors in
response to the newborn’s condition and ability to care for their newborn. Newborn Priorities in
the First Days of Life All newborns have a number of needs in the first few days of life that take
priority. They include: Initiation and maintenance of respirations Establishment of extrauterine
circulation Maintenance of fluid and electrolyte balance Control of body temperature Intake of
adequate nutrition Establishment of waste elimination Prevention of infection Establishment of a
newborn–parent/caregiver relationship Institution of developmental care or care that balances
physiologic needs and stimulation for optimal development These same needs are also the
primary needs of high-risk newborns. Because of small size, immaturity, or illness, however,
fulfilling these needs may require special equipment or care measures. Not all newborns will be
able to achieve an optimal health status secondary to extreme insults to their health during
pregnancy, the birthing process, or difficulty adjusting to extrauterine life. Indications a newborn
is having difficulty transitioning from intrauterine to extrauterine life may be first apparent by a
low Apgar score rating (see Chapter 18).
INITIATING AND MAINTAINING RESPIRATIONS
Ultimately, the prognosis of a high-risk newborn depends primarily on how the first moments of
life are managed because most deaths occurring during the first 48 hours after birth result from
the newborn’s inability to establish or maintain adequate respirations (Sharma, 2017). A newborn
who has difficulty accomplishing effective breathing may experience residual neurologic
morbidities as a result of cerebral hypoxia. Therefore, prompt, thorough, and immediate
evidence-based interventions are necessary for the best outcome. Most newborns are born with
some degree of respiratory acidosis. However, this initial acidosis is rapidly corrected by the
spontaneous onset of respirations. If respiratory activity does not begin immediately, respiratory
acidosis increases. Newborn defense mechanisms then become inadequate to reverse the process.
,This means the effort to establish respirations must be started immediately after birth because, by
2 minutes, the development of severe acidosis is already well underway (Luecke & McPherson,
2017). Any newborn who sustains any degree of asphyxia in utero, such as could occur from
cord compression, maternal anesthesia, placenta previa, intrauterine growth restriction (IUGR),
or premature separation of the placenta, may already be experiencing acidosis at birth and may
have difficulty before the first 2 minutes of life. An additional concern that ineffective
respirations create is the failure of fetal circulatory shunts to close, particularly the ductus
arteriosus. Because left-sided heart pressure is higher than right-sided pressure, blood then
circulates through the patent ductus arteriosus from the left to the right or from the aorta to the
pulmonary artery, preventing normal blood flow through the heart. Struggling to breathe and
circulate blood, the neonate is forced to use available serum glucose quickly and so may become
hypoglycemic, compounding the initial problem even further. For all these reasons, resuscitation
is important for both newborns who fail to take the first breath and for those who have difficulty
maintaining adequate respirations on their own (Wyckoff et al., 2015). Common factors that
predispose infants to respiratory difficulty, possibly requiring resuscitation, are shown in Box
26.2.
BOX 26.2 Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of Life
Low birth weight Intrauterine growth restriction Maternal history of diabetes Premature rupture
of membranes Maternal use of barbiturates or narcotics close to birth Meconium staining
Irregularities detected by fetal heart monitor during labor Cord prolapse Lowered Apgar score
(<7) at 1 or 5 minutes Postmaturity (postterm) Small for gestational age Breech birth Multiple
birth Chest, heart, or respiratory tract anomalies
Resuscitation
Approximately 10% of newborns require some assistance to begin breathing at birth. In order to
ensure newborn resuscitation is consistent among all newborns and facilities, the American
Academy of Pediatrics (AAP) has instituted a Neonatal Resuscitation Program updated at
intervals that lists steps and rationales for newborn resuscitation (Sawyer et al., 2017). Based on
these recommendations, resuscitation should follow an organized process: (a) establish an
airway, (b) expand the lungs, and (c) initiate and maintain effective ventilation. If respiratory
depression becomes so severe that a newborn’s heart begins to fail (meaning heart rate is less
than 60 beats per minute), despite effective positive-pressure ventilation, resuscitation should
then also include chest compressions (Wyckoff et al., 2015).
Airway
For a well, term newborn, usually warming, drying, and stimulating the baby by rubbing the
back is enough to initiate respirations. A rubber bulb syringe is a standard piece of equipment in
most birthing rooms and was often used in the past to suction newborns’ noses and mouths, but
because bradycardia can be associated with bulb suctioning, routine suctioning of the nose and
mouth is no longer recommended, unless there is concern that the airway is obstructed (Wyckoff
et al., 2015). If a newborn does not initiate spontaneous breathing following drying and gentle
stimulation, place the newborn under a radiant heat warmer in a “sniffing” position (head slightly
tipped back) and continue to dry and stimulate the neonate’s back to see if this additional
stimulation initiates respirations. Assess a precordial pulse over the heart and attach a pulse
oximeter to monitor oxygen saturation. Palpating the umbilical pulse can also provide a reliable
heart rate. It is reasonable to consider the application of a three-lead cardiac monitor during
, resuscitation to obtain an accurate heart rate quickly (Wyckoff et al., 2015). A newborn whose
amniotic fluid was meconium stained at birth but who is breathing does not need suctioning to
clear the airway. If the newborn whose amniotic fluid was meconium stained at birth presents
with poor muscle tone and inadequate breathing, it is important to begin the initial steps of
resuscitation under the radiant warmer. Positive-pressure ventilation should be initiated
immediately if the newborn is not breathing or the heart rate is less than 100 beats per minute
(Wyckoff et al., 2015). In most newborns, this degree of resuscitation will initiate responsive
respirations and a strong heartbeat (over 100 beats per minute). Color, muscle tone, and reflexes
will all improve. Mechanical suctioning should occur only if there is an obstruction such as a
mucus plug that is interfering with effective breathing; otherwise, it may cause bradycardia (Fig.
26.1).
A full-term newborn who still makes no effort at spontaneous respirations after these initial steps
may require insertion of an endotracheal tube so the airway is not obstructed and 21% oxygen
(air) can be effectively administered. If the heart rate or oxygen saturation levels remain low with
21% oxygen (air), oxygen may be administered to achieve a preductal oxygen saturation close to
that measured in healthy term neonates after vaginal delivery (Wyckoff et al., 2015). In the first
few seconds of life, a newborn this severely depressed may take several weak gasps of air and
then almost immediately stop breathing, resulting in a decrease in the heart rate. This period of
halted respirations is termed primary apnea. After 1 or 2 minutes of apnea (defined as a pause in
respirations longer than 20 seconds with accompanying bradycardia), the neonate again tries to
initiate respirations with a few strong gasps. Most newborns, however, cannot maintain this
effort longer than 4 or 5 minutes. After this, the respiratory effort will become weaker again and
the heart rate will continue to decrease until the newborn stops the gasping effort altogether. The
neonate then enters secondary apnea. Although usually a phenomenon that occurs after birth,
both types of apnea may occur in utero. During the period of first gasps, resuscitation attempts
are generally successful. Once a newborn is allowed to enter secondary apnea, however,
resuscitation becomes difficult and may be ineffective. Because it is impossible to distinguish
between the two periods of apnea simply by observation, resuscitation must always be started as
if secondary apnea is the phase occurring. A healthcare provider skilled in endotracheal tube
insertion should be present at the birth of all newborns identified as high risk so intubation can
be performed quickly as necessary (Wyckoff et al., 2015). Intubation is easy in theory; in
practice, the wide variation in the size of neonates’ posterior pharynges and tracheas and the
emergency conditions present under which it is attempted often make it a difficult procedure
(Fig. 26.2).
Laryngoscopes, the blades used for intubation, are equipped with different-size blades; a size
zero or one should be available for newborns. Following insertion of the laryngoscope, an
endotracheal tube is slid through the laryngoscope down into the trachea. Infants under 1,000 g
usually require a 2.5-mm endotracheal tube (think of a thin coffee straw); those over 3,000 g will
usually require a 4.0-mm tube. Because preterm newborns are at risk for hemorrhage because of
capillary fragility, gentle care during insertion is crucial.
Lung Expansion
Once an airway has been established, the newborn’s lungs need to be expanded. Healthy
newborns inflate their lungs adequately and independently with a first breath. The sound of the
neonate crying loudly is proof that lung expansion is adequate because the vocal sounds are
WITH A HIGH-RISK NEWBORN LATEST STUDY GUIDE 2026
During pregnancy, screening birthing parents for risk factors, such as being younger or older than
average maternal age, having concurrent disease conditions such as diabetes or HIV infection,
experiencing pregnancy complications such as placenta previa, or having an at-risk lifestyle such
as one that includes substance use, all of which could lead to illness in a newborn, is essential to
identify infants who may need greater than usual care at birth (Eken et al., 2016). Unfortunately,
not all instances of high-risk situations can be predicted during pregnancy or birth because even
a newborn from an uneventful pregnancy may require specialized care or may develop a problem
over the first few days of life, necessitating intervention. Any newborn, especially one who is
born dysmature (a newborn whose birth weight is inappropriately low for gestational age),
whether preterm, term, or postterm, is at risk for complications at birth or in the first few days of
life. Parents need a thorough explanation of their baby’s health because these problems may
require readmission to the hospital or additional follow-up at home. Because preterm birth in
particular has the potential for leading to high-risk newborns, several Healthy People 2030 goals
directly concern preterm births (Box 26.1).
Being able to predict if a newborn is at high risk allows for advanced preparation so that
specialized, skilled healthcare personnel can be present at the child’s birth to perform necessary
interventions, such as resuscitating a newborn who has difficulty establishing respirations.
Immediate, skilled handling of any problems that occur may help to save the newborn’s life and
prevent future problems, such as neurologic disorders (Wyckoff et al., 2015).
Nursing Process Overview ASSESSMENT
All newborns need to be assessed at birth for obvious congenital anomalies and gestational age
(number of weeks the newborn remained in utero). Both determinations can be done by the
provider who first examines the newborn. The initial assessment is performed under a
prewarmed radiant heat warmer to prevent heat loss. Continuing assessment of the high-risk
newborn involves the use of technology and equipment such as cardiac, apnea, oxygen
saturation, and blood pressure monitoring. Regardless of how many monitors are used, they do
not replace the role of frequent, close, commonsense observations by the nurse who knows the
neonate well from having cared for the newborn consistently over time. The nurse can often
sense changes before a monitor or other equipment begins to put a quantitative measurement on
the change. Carefully evaluate comments made by the parents during healthcare visits, as these
observations similarly need to be taken into consideration during the visit.
NURSING DIAGNOSIS
To establish nursing diagnoses for high-risk neonates, it is important to be aware of the usual
parameters of newborns. Examples of nursing diagnoses that center on the priority areas of care
for all newborns include: Ineffective airway clearance related to the presence of mucus or
amniotic fluid in the airway Ineffective tissue oxygenation related to breathing difficulty
Ineffective thermoregulation related to immature status Fluid volume deficit risk related to
insensible water loss Malnutrition risk, less than body requirements, related to the lack of
strength for effective sucking Infection risk related to lowered immune response because of
prematurity Impaired parenting risk related to illness in newborn at birth Readiness for
developmental care to decrease overstimulation caused by necessary lifesaving procedures
,OUTCOME IDENTIFICATION AND PLANNING
Be certain when establishing expected outcomes that they are consistent with a newborn’s
potential. A goal that implies complete recovery from a major illness, for example, may be
unrealistic for one newborn but completely appropriate for another. Be certain plans of care are
individualized, considering a newborn’s developmental level, as well as physiologic strengths,
weaknesses, and needs. Many families of a high-risk newborn will need support to care for their
neonate at home and, therefore, may need a referral for home healthcare or other resources.
Direct families to helpful websites and other resources as appropriate (see Chapter 20).
IMPLEMENTATION
Interventions for any high-risk newborn are best carried out by a consistent healthcare team and
should focus on conserving the neonate’s energy and providing a neutral thermal environment to
prevent exhaustion and hypothermia. Painful procedures should be kept to a minimum to help
the neonate achieve a sense of comfort and balance. Assisting parents to participate in care such
as bathing or feeding their newborn can help to promote bonding.
OUTCOME EVALUATION
High-risk newborns need long-term follow-up so any consequences of their birth status, such as
minimal neurologic injury, can be identified. Examples of expected outcomes include: The
neonate maintains a patent airway. The neonate demonstrates an ability to suck effectively. The
neonate tolerates procedures without accompanying apnea, bradycardia, or oxygen desaturation.
The neonate demonstrates growth and development appropriate for gestational age (AGA), birth
weight, and condition. The neonate maintains a body temperature of 98.6°F (37.0°C) in an open
crib with one added blanket. The parents visit at least once and make three telephone calls to the
neonatal nursery weekly. The parents demonstrate positive coping skills and behaviors in
response to the newborn’s condition and ability to care for their newborn. Newborn Priorities in
the First Days of Life All newborns have a number of needs in the first few days of life that take
priority. They include: Initiation and maintenance of respirations Establishment of extrauterine
circulation Maintenance of fluid and electrolyte balance Control of body temperature Intake of
adequate nutrition Establishment of waste elimination Prevention of infection Establishment of a
newborn–parent/caregiver relationship Institution of developmental care or care that balances
physiologic needs and stimulation for optimal development These same needs are also the
primary needs of high-risk newborns. Because of small size, immaturity, or illness, however,
fulfilling these needs may require special equipment or care measures. Not all newborns will be
able to achieve an optimal health status secondary to extreme insults to their health during
pregnancy, the birthing process, or difficulty adjusting to extrauterine life. Indications a newborn
is having difficulty transitioning from intrauterine to extrauterine life may be first apparent by a
low Apgar score rating (see Chapter 18).
INITIATING AND MAINTAINING RESPIRATIONS
Ultimately, the prognosis of a high-risk newborn depends primarily on how the first moments of
life are managed because most deaths occurring during the first 48 hours after birth result from
the newborn’s inability to establish or maintain adequate respirations (Sharma, 2017). A newborn
who has difficulty accomplishing effective breathing may experience residual neurologic
morbidities as a result of cerebral hypoxia. Therefore, prompt, thorough, and immediate
evidence-based interventions are necessary for the best outcome. Most newborns are born with
some degree of respiratory acidosis. However, this initial acidosis is rapidly corrected by the
spontaneous onset of respirations. If respiratory activity does not begin immediately, respiratory
acidosis increases. Newborn defense mechanisms then become inadequate to reverse the process.
,This means the effort to establish respirations must be started immediately after birth because, by
2 minutes, the development of severe acidosis is already well underway (Luecke & McPherson,
2017). Any newborn who sustains any degree of asphyxia in utero, such as could occur from
cord compression, maternal anesthesia, placenta previa, intrauterine growth restriction (IUGR),
or premature separation of the placenta, may already be experiencing acidosis at birth and may
have difficulty before the first 2 minutes of life. An additional concern that ineffective
respirations create is the failure of fetal circulatory shunts to close, particularly the ductus
arteriosus. Because left-sided heart pressure is higher than right-sided pressure, blood then
circulates through the patent ductus arteriosus from the left to the right or from the aorta to the
pulmonary artery, preventing normal blood flow through the heart. Struggling to breathe and
circulate blood, the neonate is forced to use available serum glucose quickly and so may become
hypoglycemic, compounding the initial problem even further. For all these reasons, resuscitation
is important for both newborns who fail to take the first breath and for those who have difficulty
maintaining adequate respirations on their own (Wyckoff et al., 2015). Common factors that
predispose infants to respiratory difficulty, possibly requiring resuscitation, are shown in Box
26.2.
BOX 26.2 Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of Life
Low birth weight Intrauterine growth restriction Maternal history of diabetes Premature rupture
of membranes Maternal use of barbiturates or narcotics close to birth Meconium staining
Irregularities detected by fetal heart monitor during labor Cord prolapse Lowered Apgar score
(<7) at 1 or 5 minutes Postmaturity (postterm) Small for gestational age Breech birth Multiple
birth Chest, heart, or respiratory tract anomalies
Resuscitation
Approximately 10% of newborns require some assistance to begin breathing at birth. In order to
ensure newborn resuscitation is consistent among all newborns and facilities, the American
Academy of Pediatrics (AAP) has instituted a Neonatal Resuscitation Program updated at
intervals that lists steps and rationales for newborn resuscitation (Sawyer et al., 2017). Based on
these recommendations, resuscitation should follow an organized process: (a) establish an
airway, (b) expand the lungs, and (c) initiate and maintain effective ventilation. If respiratory
depression becomes so severe that a newborn’s heart begins to fail (meaning heart rate is less
than 60 beats per minute), despite effective positive-pressure ventilation, resuscitation should
then also include chest compressions (Wyckoff et al., 2015).
Airway
For a well, term newborn, usually warming, drying, and stimulating the baby by rubbing the
back is enough to initiate respirations. A rubber bulb syringe is a standard piece of equipment in
most birthing rooms and was often used in the past to suction newborns’ noses and mouths, but
because bradycardia can be associated with bulb suctioning, routine suctioning of the nose and
mouth is no longer recommended, unless there is concern that the airway is obstructed (Wyckoff
et al., 2015). If a newborn does not initiate spontaneous breathing following drying and gentle
stimulation, place the newborn under a radiant heat warmer in a “sniffing” position (head slightly
tipped back) and continue to dry and stimulate the neonate’s back to see if this additional
stimulation initiates respirations. Assess a precordial pulse over the heart and attach a pulse
oximeter to monitor oxygen saturation. Palpating the umbilical pulse can also provide a reliable
heart rate. It is reasonable to consider the application of a three-lead cardiac monitor during
, resuscitation to obtain an accurate heart rate quickly (Wyckoff et al., 2015). A newborn whose
amniotic fluid was meconium stained at birth but who is breathing does not need suctioning to
clear the airway. If the newborn whose amniotic fluid was meconium stained at birth presents
with poor muscle tone and inadequate breathing, it is important to begin the initial steps of
resuscitation under the radiant warmer. Positive-pressure ventilation should be initiated
immediately if the newborn is not breathing or the heart rate is less than 100 beats per minute
(Wyckoff et al., 2015). In most newborns, this degree of resuscitation will initiate responsive
respirations and a strong heartbeat (over 100 beats per minute). Color, muscle tone, and reflexes
will all improve. Mechanical suctioning should occur only if there is an obstruction such as a
mucus plug that is interfering with effective breathing; otherwise, it may cause bradycardia (Fig.
26.1).
A full-term newborn who still makes no effort at spontaneous respirations after these initial steps
may require insertion of an endotracheal tube so the airway is not obstructed and 21% oxygen
(air) can be effectively administered. If the heart rate or oxygen saturation levels remain low with
21% oxygen (air), oxygen may be administered to achieve a preductal oxygen saturation close to
that measured in healthy term neonates after vaginal delivery (Wyckoff et al., 2015). In the first
few seconds of life, a newborn this severely depressed may take several weak gasps of air and
then almost immediately stop breathing, resulting in a decrease in the heart rate. This period of
halted respirations is termed primary apnea. After 1 or 2 minutes of apnea (defined as a pause in
respirations longer than 20 seconds with accompanying bradycardia), the neonate again tries to
initiate respirations with a few strong gasps. Most newborns, however, cannot maintain this
effort longer than 4 or 5 minutes. After this, the respiratory effort will become weaker again and
the heart rate will continue to decrease until the newborn stops the gasping effort altogether. The
neonate then enters secondary apnea. Although usually a phenomenon that occurs after birth,
both types of apnea may occur in utero. During the period of first gasps, resuscitation attempts
are generally successful. Once a newborn is allowed to enter secondary apnea, however,
resuscitation becomes difficult and may be ineffective. Because it is impossible to distinguish
between the two periods of apnea simply by observation, resuscitation must always be started as
if secondary apnea is the phase occurring. A healthcare provider skilled in endotracheal tube
insertion should be present at the birth of all newborns identified as high risk so intubation can
be performed quickly as necessary (Wyckoff et al., 2015). Intubation is easy in theory; in
practice, the wide variation in the size of neonates’ posterior pharynges and tracheas and the
emergency conditions present under which it is attempted often make it a difficult procedure
(Fig. 26.2).
Laryngoscopes, the blades used for intubation, are equipped with different-size blades; a size
zero or one should be available for newborns. Following insertion of the laryngoscope, an
endotracheal tube is slid through the laryngoscope down into the trachea. Infants under 1,000 g
usually require a 2.5-mm endotracheal tube (think of a thin coffee straw); those over 3,000 g will
usually require a 4.0-mm tube. Because preterm newborns are at risk for hemorrhage because of
capillary fragility, gentle care during insertion is crucial.
Lung Expansion
Once an airway has been established, the newborn’s lungs need to be expanded. Healthy
newborns inflate their lungs adequately and independently with a first breath. The sound of the
neonate crying loudly is proof that lung expansion is adequate because the vocal sounds are
