# A nurse is caring for a premature neonate born at 28 weeks gestation who has been diagnosed with respiratory distress syndrome (RDS). The neonate is currently on mechanical ventilation with surfactant therapy completed 2 hours ago. Which assessment finding should be the nurse's highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543244 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is caring for a premature neonate born at 28 weeks gestation who has been diagnosed with respiratory distress syndrome (RDS). The neonate is currently on mechanical ventilation with surfactant therapy completed 2 hours ago. Which assessment finding should be the nurse's highest priority? ## 보기 1. Sudden decrease in oxygen saturation with increased work of breathing **✔ 정답** 2. Mild peripheral cyanosis around the hands and feet 3. Heart rate of 145 beats per minute 4. Decreased urine output over the past 4 hours **정답: 1** ## 해설 Sudden decrease in oxygen saturation with increased work of breathing indicates life-threatening complications like pneumothorax or ventilator malfunction requiring immediate intervention. Other findings (mild cyanosis, normal heart rate, decreased urine output) are less urgent in this context. ## 심화 해설 Clinical Priority in Post-Surfactant Neonate The neonate in this scenario, born at 28 weeks gestation, has a primary problem of surfactant deficiency leading to respiratory distress syndrome (RDS). Surfactant therapy works by reducing alveolar surface tension, thereby improving lung compliance and gas exchange. The period following surfactant administration is critical, as the therapy is intended to stabilize the pulmonary status. However, the premature lung remains fragile, and the patient is dependent on mechanical ventilation. The highest priority assessment finding is a sudden decrease in oxygen saturation with increased work of breathing. This clinical presentation is a hallmark of an acute pulmonary complication, most immediately a pneumothorax. The underlying pathophysiology involves the rapid improvement in lung compliance following surfactant therapy. As the alveoli open and compliance increases, if ventilator settings are not promptly weaned, the delivered tidal volumes can become excessively high for the newly recruited lung tissue, leading to volutrauma and alveolar rupture. Air then leaks into the pleural space, causing the lung to collapse. This is a life-threatening emergency requiring immediate intervention to prevent severe hypoxia and cardiovascular collapse. The provided evidence underscores the risks associated with mechanical ventilation in the context of RDS management. While surfactant is life-saving, the traditional delivery method via endotracheal intubation and mechanical ventilation is associated with procedure-related complications and an increased risk of bronchopulmonary dysplasia (BPD) [3]. This has driven the development of less invasive surfactant administration (LISA) techniques, which aim to maintain spontaneous breathing and avoid the barotrauma and volutrauma linked to positive pressure ventilation [3, 4]. A study comparing LISA and INSURE (INtubation-SURfactant-Extubation) techniques highlights that treatment failure, often defined by the need for a second surfactant dose or escalation of respiratory support, is a key outcome, reflecting the instability of these patients [4]. Even when surfactant is delivered via minimally invasive methods, the risk of respiratory deterioration from air leak syndromes or tube malposition remains a primary nursing concern. The other options represent findings that are either expected or of lower acuity. Mild peripheral cyanosis (acrocyanosis) is a common and often benign finding in the immediate newborn period related to vasomotor instability and is not a central perfusion crisis. A heart rate of 145 beats per minute is within the normal range for a preterm neonate. While decreased urine output over 4 hours is a concerning sign that could indicate hypoperfusion or acute kidney injury, it is a more gradual indicator of clinical status. In contrast, a sudden desaturation with increased respiratory effort signals an immediate threat to oxygenation and ventilation, making it the nurse's highest priority for assessment and rapid response. References (research sources) - [3]Non-Invasive Surfactant Administration in Preterm Infants.Research articleBudajaja F, Lahage N, Hand IL. (2026) · DOI: 10.3390/children13010150 - [4]Comparison of LISA and INSURE techniques for surfactant administration: a multicentre retrospective study.Research articlePanza R, Caravita R, Valenzano L, Martinelli D, Farella I, Guida P, Quercia M, Latorre G, Laforgia N. (2026) · DOI: 10.1007/s00431-026-07118-8 ## 임상 시나리오 Clinical Guide: Post-Surfactant Monitoring for Pneumothorax **Pathophysiology:** Surfactant therapy rapidly improves lung compliance in RDS. If ventilator pressures are not immediately weaned, the same settings deliver a much larger tidal volume to the newly compliant lungs, causing volutrauma and risk of alveolar rupture (pneumothorax). **Priority Assessment:** The earliest and most critical sign is a sudden, unexplained drop in oxygen saturation accompanied by increased work of breathing (grunting, retractions, nasal flaring). This indicates a tension pneumothorax until proven otherwise. **Immediate Nursing Actions:** - Assess for tracheal deviation and absent breath sounds on the affected side. - Prepare for emergency needle thoracentesis and chest tube insertion. - Increase FiO2 to 100% and prepare to manually ventilate. **Prevention:** Anticipate the need for rapid ventilator weaning. Closely monitor tidal volumes and blood gases immediately after surfactant administration to adjust peak inspiratory pressure (PIP) and positive end-expiratory pressure (PEEP). ## 핵심 개념 - **Respiratory Distress Syndrome** — Respiratory distress syndrome. A condition that primarily occurs in premature infants due to a deficiency of pulmonary surfactant, characterized by alveolar collapse and severe respiratory difficulty. - **Surfactant Therapy** — Surfactant therapy. A treatment in which artificial surfactant is administered endotracheally to newborns with RDS to lower lung surface tension and maintain lung expansion. - **Pneumothorax** — Pneumothorax. A condition where air leaks into the pleural space between the lung and chest wall, causing the lung to collapse. There is a risk of occurrence when lung compliance changes rapidly after surfactant administration. - **Mechanical Ventilation** — Mechanical ventilation. A device that artificially assists or replaces a patient's breathing. It is essential for managing RDS in premature infants. - **Acrocyanosis** — Peripheral cyanosis. Cyanosis limited to peripheral areas such as the hands, feet, and around the lips, a physiological phenomenon commonly seen in the neonatal period, especially in premature infants. Must be distinguished from central cyanosis. ## 같은 주제 문제 - [A nurse is assessing a 30-week gestation preterm infant who was born 2 hours ago. 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