A newborn is reported to have breastfed very well during the first successful feeding after birth.
The baby is now 4 hours old and has not had a second feeding.
The nurse would:

Choice B rationale: Hyperglycemia is related to elevated blood glucose levels and is not a symptom of respiratory distress syndrome (RDS) in infants.

Choice C rationale: Tremors can be caused by various conditions, including metabolic imbalances or drug withdrawal. They are not specific to respiratory distress syndrome (RDS).

Choice D rationale: Intercostal retractions are a sign of increased work of breathing and respiratory distress. In infants with respiratory distress syndrome (RDS), the underdeveloped lungs can lead to difficulty in breathing, causing the muscles between the ribs to pull inwards during inspiration. This is a common symptom of RDS.

Choice A rationale

The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.

Choice B rationale

The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.

Choice C rationale

The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.

Choice D rationale

The Apgar score includes five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Heart rate 60 scores 1, weak cry scores 1, partial flexion of extremities scores 1, weak suck scores 1, gray color scores 0. Total score: 4.