Newborn Nursing Care Q 35
A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome?
A. Hypotension and Bradycardia
B. Tachypnea and retractions
C. Acrocyanosis and grunting
D. The presence of a barrel chest with grunting
Correct Answer: B. Tachypnea and retractions
Respiratory distress syndrome (RDS) usually affects premature babies. It is caused by the absence or lack of surfactant, a phospholipid that lines the alveoli and reduces the surface tension to keep the alveoli from collapsing on expiration. Surfactant is not formed until the 34th week of gestation that is why premature infants are vulnerable.
Option B: Infants who develop RDS have periods during the day when they are free of symptoms because of an initial release of surfactant. The initial signs of respiratory distress includes tachypnea (60 breaths per minute), sternal and subcostal retractions, nasal flaring, cyanotic mucous membranes.
Options A, C, & D: These are late signs (after a few hours) of respiratory distress as its intensity increases. Acrocyanosis is the blue or cyanotic discoloration of the extremities. Expiratory grunting is when the infant closes the glottis in an attempt to increase pressure in the alveoli on expiration in order to keep them from collapsing. Additionally, auscultation may reveal fine rales and diminished breath sounds due to poor air entry.