A nurse is assessing a pre-term newborn who was born at 28 weeks of gestation.

Which of the following findings indicates a possible diagnosis of respiratory distress syndrome (RDS)?

Tachypnea and grunting

Bradycardia and cyanosis

Apnea and nasal flaring

All of the above

Answer and Explanation

The Correct Answer is D

All of the above.

Respiratory distress syndrome (RDS) is a condition that affects preterm newborns who have immature lungs and lack sufficient surfactant.

Surfactant is a substance that helps keep the alveoli open and prevents them from collapsing.

Without enough surfactant, the newborn has difficulty breathing and may develop hypoxia and acidosis.

Choice A is wrong because tachypnea and grunting are signs of respiratory distress, but they are not specific to RDS.

They can also be caused by other conditions such as transient tachypnea of the newborn, pneumonia, or congenital heart defects.

Choice B is wrong because bradycardia and cyanosis are also signs of respiratory distress, but they are not specific to RDS.

They can also be caused by other conditions such as hypothermia, hypoglycemia, or sepsis.

Choice C is wrong because apnea and nasal flaring are also signs of respiratory distress, but they are not specific to RDS.

They can also be caused by other conditions such as intracranial ...

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Correct Answer is A

Explanation

Assess fetal heart rate and activity.

The nurse should identify that a client who reports a sudden gush of fluid from her vagina is at risk forpremature rupture of membranes (PROM), which can lead toinfection,cord prolapse, andfetal distress.Therefore, the priority action is to assess the fetal heart rate and activity to monitor for signs of hypoxia or distress.

Choice B is wrong because performing a nitrazine test on the fluid is not the first action.A nitrazine test can confirm the presence of amniotic fluid by detecting its alkaline pH, but it is not as urgent as assessing the fetal well-being.

Choice C is wrong because administering oxytocin (Pitocin) IV infusion is contraindicated in this situation.Oxytocin is used to induce or augment labor, but it can causeuterine hyperstimulation,fetal distress, andplacental abruptionif given to a client who has PROM.

Choice D is wrong because placing the client in Trendelenburg position is not recommended for a client who has PROM.Trendelenburg position can increase the risk ofcord prolapseandaspirationin this situation.

A. Encourage the parents to touch and talk to the infant through the incubator ports B. Limit the parents’ visitation time to prevent overstimulation of the infant C. Advise the parents to avoid eye contact with the infant until he is stable D. Restrict the parents from holding or feeding the infant until he is discharged.

Correct Answer is A

Explanation

Encouraging the parents to touch and talk to the infant through the incubator ports can promote bonding between the infant and the parents.Bonding is the intense attachment that develops between parents and their baby, and it is essential for the baby’s social and cognitive development.Touch and communication are some of the ways that babies bond with their parents.

Choice B is wrong because limiting the parents’ visitation time can disrupt the bonding process and make the parents feel less involved in their baby’s care.

Choice C is wrong because eye contact is another way of bonding with babies, and it can help them feel secure and loved.

Choice D is wrong because holding and feeding the infant are also important ways of bonding, and they should not be restricted unless medically necessary.

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A nurse is assessing a pre-term newborn who was born at 28 weeks of gestation. Which of the following findings indicates a possible diagnosis of respiratory distress syndrome (RDS)?

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A nurse is assessing a pre-term newborn who was born at 28 weeks of gestation.

Which of the following findings indicates a possible diagnosis of respiratory distress syndrome (RDS)?