# A nurse is assessing a 32-week preterm newborn who was born 4 hours ago. Which assessment finding would be the most significant indicator of respiratory distress syndrome (RDS)? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543240 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is assessing a 32-week preterm newborn who was born 4 hours ago. Which assessment finding would be the most significant indicator of respiratory distress syndrome (RDS)? ## 보기 1. Heart rate of 180 beats per minute with irregular rhythm 2. Expiratory grunting with sternal and intercostal retractions **✔ 정답** 3. Acrocyanosis of hands and feet with pink central color 4. Respiratory rate of 70 breaths per minute with shallow breathing **정답: 2** ## 해설 Expiratory grunting with retractions is the most specific indicator of RDS in preterm infants, reflecting compensatory efforts to maintain lung volume. Other findings like tachycardia, acrocyanosis, or tachypnea are less specific and can occur in other conditions. ## 심화 해설 Understanding the Pathophysiology of Respiratory Distress Syndrome (RDS) To interpret this assessment finding, it is crucial to first understand the underlying mechanism. Neonatal RDS is primarily caused by a deficiency of pulmonary surfactant, a lipoprotein complex that reduces surface tension within the alveoli [1]. Without adequate surfactant, the alveoli collapse during expiration (atelectasis). The infant must generate high intrathoracic pressure to re-expand the lungs with each breath. This physiological struggle manifests as a specific cluster of clinical signs, which are the most direct and significant indicators of the disease. Analyzing the Correct Answer: Expiratory Grunting and Retractions The finding of expiratory grunting with sternal and intercostal retractions is the most significant indicator of RDS. This combination directly reflects the body's compensatory response to alveolar collapse. - Expiratory Grunting: This is a physiological attempt to create positive end-expiratory pressure (PEEP). The infant exhales against a partially closed glottis, which helps keep the unstable alveoli open at the end of expiration, improving gas exchange. Its presence is a hallmark sign of significant respiratory distress and surfactant deficiency . - Sternal and Intercostal Retractions: These occur because the compliant chest wall of a preterm infant is pulled inward as the diaphragm descends forcefully to generate the high negative intrathoracic pressure needed to open collapsed alveoli. This visible "tugging" of the chest wall is a direct, objective sign of increased work of breathing due to poor lung compliance. The combination of these two signs—one audible (grunting) and one visible (retractions)—provides a powerful bedside assessment of the mechanical failure at the core of RDS. Clinical decision-making for interventions like surfactant administration often relies on such signs of escalating respiratory distress . Why the Other Options Are Less Specific A systematic comparison reveals why the other findings, while potentially abnormal, are not the most significant or specific indicators of RDS in this context. - Option 1: Heart rate of 180 beats per minute with irregular rhythm. A heart rate of 180 beats per minute is tachycardic for a newborn but is a non-specific sign of many conditions, including pain, hypovolemia, or sepsis. While tachycardia can accompany RDS as hypoxia worsens, it is a downstream effect, not a primary indicator of the pulmonary mechanics failure. An irregular rhythm in a newborn is often a benign sinus arrhythmia and is not a classic hallmark of RDS. - Option 3: Acrocyanosis of hands and feet with pink central color. This describes a normal, benign finding in newborns within the first 24-48 hours of life. Acrocyanosis is caused by vasomotor instability and peripheral vasoconstriction, not central hypoxemia. The presence of a pink central color confirms that oxygenation is adequate, making this a finding that rules out significant respiratory distress. - Option 4: Respiratory rate of 70 breaths per minute with shallow breathing. A respiratory rate of 70 breaths per minute is tachypneic (normal is 30-60) and is a common, early sign of respiratory distress. However, tachypnea is a non-specific compensatory mechanism for many conditions, such as transient tachypnea of the newborn (TTN) or sepsis. By itself, it lacks the specificity of the mechanical signs of grunting and retractions, which point more definitively to surfactant-deficient lungs and alveolar collapse. Clinical Application and Diagnostic Reasoning For the NCLEX-RN candidate, this question tests the ability to prioritize and distinguish between general signs of distress and the pathognomonic signs of a specific disease process. While tachypnea and tachycardia are important data points, the presence of expiratory grunting and retractions in a 32-week preterm infant creates a high-probability clinical picture of RDS. This assessment directly reflects the increased work of breathing and the physiological attempt to maintain functional residual capacity, which are the core problems resulting from surfactant deficiency [1]. Recognizing this cluster of signs is critical for the nurse to promptly escalate care, anticipate the need for respiratory support, and prepare for potential surfactant administration based on established clinical thresholds . References (research sources) - [1]Research progress on biomarkers associated with neonatal respiratory distress syndrome.Research articleXiong M, Deng J, Zhao J. (2026) · DOI: 10.3389/fped.2026.1811632 ## 임상 시나리오 Clinical Guide: Assessing for Respiratory Distress Syndrome (RDS) in a Preterm Newborn Pathophysiology & Clinical Correlation RDS results from surfactant deficiency, which leads to diffuse alveolar collapse (atelectasis). The infant must generate high negative intrathoracic pressure to re-expand the lungs. This struggle produces the hallmark clinical signs: **expiratory grunting** (a physiologic attempt to create auto-PEEP by exhaling against a partially closed glottis) and **sternal/intercostal retractions** (inward pulling of the compliant chest wall during forceful diaphragmatic contraction). These signs are direct manifestations of the underlying pathophysiology and are more specific than isolated tachypnea or heart rate changes. Focused Assessment Priorities - **Work of Breathing:** Assess for nasal flaring, grunting, and retractions (subcostal, intercostal, suprasternal). The Silverman-Anderson index can be used to score severity. - **Auscultation:** Breath sounds are often diminished due to poor air entry from atelectasis. Fine crackles may be heard. - **Oxygen Saturation:** Continuous pulse oximetry is essential. Pre-ductal (right hand) and post-ductal (either foot) saturations help identify persistent pulmonary hypertension or right-to-left shunting. - **Central vs. Peripheral Cyanosis:** Differentiate central cyanosis (lips, tongue, trunk) indicating hypoxemia from acrocyanosis (hands/feet), which is a normal finding in the first hours of life. Nursing Interventions & Monitoring - Maintain a neutral thermal environment to minimize oxygen consumption. Use a pre-warmed radiant warmer or incubator with servo control. - Position the infant supine or prone with the head in a neutral, slightly extended position to maintain airway patency. - Provide minimal stimulation and cluster care to reduce energy expenditure and prevent hypoxic episodes. - Anticipate the need for respiratory support: continuous positive airway pressure (CPAP) is often the first-line intervention to maintain functional residual capacity. Prepare for possible intubation and surfactant administration if distress worsens. - Monitor blood gases closely. Rising PaCO2 and falling pH indicate worsening respiratory failure. ## 핵심 개념 - **Respiratory Distress Syndrome (RDS)** — A neonatal breathing disorder primarily caused by pulmonary surfactant deficiency, leading to alveolar collapse, impaired gas exchange, and severe respiratory distress. - **Expiratory Grunting** — A compensatory mechanism where the infant exhales against a partially closed glottis to generate positive end-expiratory pressure (PEEP), preventing alveolar collapse at the end of expiration. - **Sternal and Intercostal Retractions** — Visible inward pulling of the chest wall between the ribs or at the sternum during inspiration, indicating the use of high negative intrathoracic pressure to expand stiff, noncompliant lungs. - **Pulmonary Surfactant** — A lipoprotein complex secreted by type II alveolar cells that reduces surface tension within the alveoli, preventing their collapse during exhalation. - **Acrocyanosis** — Bluish discoloration of the hands and feet with a pink central body color, a common and usually benign finding in newborns due to peripheral vasomotor instability, not central hypoxia. ## 같은 주제 문제 - [A nurse is assessing a 30-week gestation preterm infant who was born 2 hours ago. Which as…](https://mymerci.kr/pages/nclex_q.php?qn_id=543238) - [A nurse is assessing a 28-week gestation preterm infant who was born 2 hours ago. Which as…](https://mymerci.kr/pages/nclex_q.php?qn_id=543239) - [A premature infant born at 30 weeks gestation is diagnosed with respiratory distress syndr…](https://mymerci.kr/pages/nclex_q.php?qn_id=543241) - [A nurse is caring for a preterm infant diagnosed with respiratory distress syndrome (RDS).…](https://mymerci.kr/pages/nclex_q.php?qn_id=543242) - [A nurse is caring for a 35-week late preterm infant with mild respiratory distress. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=543243) - [A nurse is caring for a premature neonate born at 28 weeks gestation who has been diagnose…](https://mymerci.kr/pages/nclex_q.php?qn_id=543244) - [A premature infant born at 32 weeks gestation is admitted to the NICU with signs of respir…](https://mymerci.kr/pages/nclex_q.php?qn_id=543245) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._