A nurse is caring for a newborn with respiratory distress syndrome who weighs 3,000 grams. Which nursing intervention should be the priority?
1Monitor blood glucose levels every 2-4 hours for the first 24 hours✓ 정답
2Assess for signs of respiratory distress syndrome every 2-4 hours
3Evaluate for congenital heart defects every 2-4 hours
4Check for signs of polycythemia every 2-4 hours
해설
LGA newborns are at high risk for hypoglycemia from maternal hyperglycemia, so monitoring blood glucose is the priority intervention. Other interventions are important but less immediate.
Understanding the Priority for a Newborn with Respiratory Distress Syndrome
When caring for a newborn with respiratory distress syndrome (RDS), the immediate threat to physiological stability is compromised gas exchange. The cornerstone of management is respiratory support, most commonly delivered via nasal continuous positive airway pressure (NCPAP). While NCPAP is life-sustaining, it introduces specific, preventable risks that the nurse must prioritize. The provided evidence identifies that the main risks associated with NCPAP use are pressure injuries, infection at the device site, and related complications, which can affect long-term outcomes [1]. Therefore, preventing these pressure injuries must be a priority in nursing care [1].
This clinical reality directly informs the prioritization of nursing interventions. A newborn weighing 3,000 grams on NCPAP has a nasally applied interface that exerts constant pressure on fragile, underdeveloped skin. The pathophysiological mechanism involves localized ischemia caused by device pressure exceeding capillary perfusion pressure, leading to tissue necrosis and skin breakdown within hours. A nasal pressure injury not only causes pain and risk of infection but can also lead to nasal septum deformity, a serious long-term complication. Because the prevention of these injuries is explicitly identified as a nursing care priority [1], the nurse's immediate and continuous assessment must focus on the integrity of the skin and nares under the device.
While monitoring blood glucose, evaluating for congenital heart defects, and checking for polycythemia are all valid components of comprehensive newborn assessment, they are secondary to a direct, device-related complication for a patient with a confirmed diagnosis of RDS on NCPAP. The priority nursing intervention is the one that addresses the most immediate risk associated with the primary treatment. For this newborn, that risk is a pressure injury from the respiratory support device. The nurse must perform systematic skin assessments at frequent intervals, specifically checking the nasal septum, columella, and surrounding tissue for early signs of blanching, erythema, or breakdown every 2-4 hours. This aligns with the principle that preventing pressure injuries is a priority in nursing care during NCPAP treatment [1].
References (research sources)
[1]
Prevention of Pressure Injuries During Nasal Continuous Positive Airway Pressure in Newborns: A Non-pharmacological Intervention Trial.Research articleLagostina E, Ferrario S, Zorz A, Sorrentino G, Fassino B, Colnaghi M, Mosca F, Fumagalli M, Plevani L. (2026) · DOI: 10.1111/nicc.70444
A 3,000-gram newborn with Respiratory Distress Syndrome (RDS) is placed on Nasal Continuous Positive Airway Pressure (NCPAP). The nurse's priority is to prevent device-related pressure injuries, a leading complication of this life-sustaining therapy.
Assessment
Inspect nares, nasal septum, and surrounding skin every 2-4 hours for erythema, blanching, or breakdown.
Assess the fit and position of nasal prongs; ensure they do not impinge on the nasal septum or create excessive pressure on the alae.
Document skin integrity using a standardized tool (e.g., Neonatal Skin Condition Score).
Intervention
Use a protective barrier, such as a hydrocolloid dressing, on the nasal septum and under prong contact points as per unit protocol.
Alternate NCPAP interfaces (e.g., nasal mask vs. binasal prongs) if clinically feasible and per provider order to redistribute pressure.
Ensure proper humidification of inspired gases to prevent mucosal drying and breakdown.
Education
Teach parents the rationale for frequent skin checks and the importance of the NCPAP device in supporting their baby's breathing.
Instruct on signs of skin irritation to report to the nurse immediately.
This guidance prioritizes the prevention of iatrogenic harm from a critical intervention, aligning with the NCLEX focus on safety and complication prevention.
Respiratory Distress Syndrome (RDS) — A breathing disorder in premature newborns caused by a lack of surfactant, leading to alveolar collapse and impaired gas exchange.
Nasal Continuous Positive Airway Pressure (NCPAP) — A non-invasive respiratory support that delivers constant air pressure via nasal prongs to keep alveoli open, a primary treatment for RDS.
Pressure Injury — Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device, caused by intense and/or prolonged pressure.