# A nurse is assessing a newborn who was delivered via cesarean section 2 hours ago. Which assessment finding would be most indicative of respiratory distress syndrome (RDS)? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543257 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is assessing a newborn who was delivered via cesarean section 2 hours ago. Which assessment finding would be most indicative of respiratory distress syndrome (RDS)? ## 보기 1. Respiratory rate of 80 breaths per minute with nasal flaring and mild intercostal retractions **✔ 정답** 2. Heart rate of 180 beats per minute with poor peripheral perfusion and weak pulses 3. Temperature of 96.5°F (35.8°C) with poor muscle tone and lethargy 4. Blood glucose level of 35 mg/dL with jitteriness and poor feeding **정답: 1** ## 해설 TTN presents with tachypnea (>60 bpm) and mild distress signs like nasal flaring, while other options indicate cardiac, thermoregulatory, or metabolic issues. ## 심화 해설 Understanding Respiratory Distress Syndrome (RDS) in the Context of Cesarean Section The correct answer is 1. The assessment finding most indicative of respiratory distress syndrome (RDS) in a newborn delivered via cesarean section is a respiratory rate of 80 breaths per minute with nasal flaring and mild intercostal retractions. Why This Finding Points to RDS RDS is primarily a disease of surfactant deficiency, leading to alveolar collapse and poor gas exchange. The clinical presentation is dominated by signs of increased work of breathing. A respiratory rate above 60 breaths per minute (tachypnea), nasal flaring (which decreases airway resistance), and intercostal retractions (reflecting high negative intrathoracic pressure needed to expand stiff lungs) are classic, direct signs of the pulmonary pathology. These findings represent the body's compensatory mechanisms for a primary lung problem. The Pathophysiology of RDS After Cesarean Section The link between elective cesarean section (CS) and RDS is a critical concept for NCLEX-RN preparation. As highlighted in the provided research on the knee-to-chest flexion maneuver, the risk of neonatal respiratory distress increases in planned CS due to the "absence of labor" [2]. During a vaginal delivery, the physical compression of the fetal thorax in the birth canal and the hormonal changes of labor facilitate the clearance of fetal lung fluid. Without this process, the newborn retains excess lung liquid, which occupies alveolar space and impairs gas exchange, mimicking or exacerbating surfactant deficiency [2]. This physiological mechanism explains why a post-CS newborn is at higher risk and why you must be vigilant for signs of respiratory distress. Why the Other Options Are Less Indicative of RDS - Option 2 (Heart rate of 180 bpm with poor perfusion): While tachycardia can be a late sign of hypoxia from severe RDS, this cluster of findings—tachycardia, poor peripheral perfusion, and weak pulses—is more classically associated with cardiogenic shock, sepsis, or a congenital heart defect. It indicates a primary cardiovascular compromise rather than a primary pulmonary condition. - Option 3 (Temperature of 96.5°F (35.8°C) with lethargy): Hypothermia and poor muscle tone are nonspecific signs of cold stress, sepsis, or hypoglycemia. Cold stress can worsen RDS by increasing oxygen consumption and inducing acidosis, but it is not the defining diagnostic feature of the syndrome itself. - Option 4 (Blood glucose of 35 mg/dL with jitteriness): This is a classic presentation of hypoglycemia. Jitteriness, poor feeding, and lethargy are neuroglycopenic symptoms. While an infant with RDS can develop hypoglycemia due to increased metabolic demand, this finding directly points to a metabolic, not a primary respiratory, etiology. Key NCLEX-RN Clinical Reasoning When analyzing assessment findings, you must differentiate between a problem's direct, defining characteristics and its secondary or late effects. The question asks for the finding "most indicative" of RDS. The triad of tachypnea, nasal flaring, and retractions is the direct clinical manifestation of the stiff, fluid-filled lungs central to RDS pathophysiology [2]. For high-risk populations, such as infants of diabetic mothers, this assessment is even more critical, as they have a significantly elevated risk of developing RDS, a fact that drives ongoing research into prenatal prediction methods . Your immediate nursing priority is to recognize these early signs of increased work of breathing to intervene with oxygen therapy, thermoregulation, and respiratory support, preventing progression to respiratory failure.References (research sources) - [2]Acceptability of the knee-to-chest flexion maneuver to reduce neonatal respiratory distress after elective cesarean section: a qualitative study among healthcare providers.Research articleShirima FL, Manteiga KR, Mchome B, Keus A, Mmbaga BT, Te Pas AB, van den Akker T. (2026) · DOI: 10.1080/14767058.2026.2666475 ## 임상 시나리오 Clinical Context: RDS After Cesarean Section The absence of labor in an elective cesarean section prevents the catecholamine surge and thoracic compression that normally clear fetal lung fluid. This increases the risk for both Transient Tachypnea of the Newborn (TTN) and Respiratory Distress Syndrome (RDS), with RDS being a more severe surfactant-deficiency state. Key Assessment Findings - **Classic Triad:** Tachypnea (>60 breaths/min), nasal flaring, and intercostal/substernal retractions are hallmark signs of increased work of breathing due to poor lung compliance. - **Auscultation:** Diminished breath sounds with possible fine inspiratory crackles. Expiratory grunting is a compensatory mechanism to generate intrinsic PEEP and prevent alveolar collapse. - **Progression:** Signs typically appear within the first few hours after birth and may worsen over 24-48 hours as surfactant stores are consumed. Nursing Interventions - **Respiratory Support:** Maintain airway patency, provide supplemental oxygen to keep SpO2 within target range (typically 90-95%), and position the infant to optimize ventilation. Continuous Positive Airway Pressure (CPAP) is often the first-line intervention for moderate distress. - **Thermoregulation:** Place the infant in a pre-warmed radiant warmer or incubator. Hypothermia increases oxygen consumption and can worsen acidosis, exacerbating respiratory distress. - **Nutrition & Fluids:** Initiate IV fluids (e.g., D10W) as ordered to prevent hypoglycemia and dehydration, as oral feeding is often contraindicated with a high respiratory rate to prevent aspiration. - **Monitoring:** Continuous pulse oximetry, cardiorespiratory monitoring, and serial blood gas analysis to assess for respiratory acidosis and hypoxemia. Differential Diagnosis: RDS vs. TTN - **RDS:** Progressive worsening over 24-48 hours. Chest X-ray shows a diffuse "ground-glass" appearance with air bronchograms. Often requires surfactant replacement therapy. - **TTN:** Usually resolves within 24-72 hours with supportive care. Chest X-ray shows prominent perihilar streaking and fluid in the fissures. Surfactant therapy is not indicated. ## 핵심 개념 - **Transient Tachypnea of the Newborn** — Transient tachypnea of the newborn. A temporary respiratory distress condition that occurs mainly in full-term or late preterm infants, especially after cesarean delivery, due to delayed absorption of fetal lung fluid. - **Tachypnea** — Tachypnea. In newborns, this generally refers to a respiratory rate exceeding 60 breaths per minute. - **Intercostal Retractions** — Intercostal retractions. This is a phenomenon where the spaces between the ribs are pulled inward during breathing, and it is a sign of respiratory distress indicating increased airway resistance. - **Nasal Flaring** — Nasal flaring. This is a phenomenon where the nostrils widen during breathing, and it is a sign of the body's effort to lower airway resistance and increase airflow. - **Cesarean Section** — Cesarean section. A surgical procedure that delivers the fetus through incisions in the abdomen and uterus, and is one of the major risk factors for TTN. ## 같은 주제 문제 - [A nurse is caring for a newborn who was delivered via cesarean section 2 hours ago. Which …](https://mymerci.kr/pages/nclex_q.php?qn_id=543255) - [A newborn delivered via cesarean section at 38 weeks gestation is experiencing respiratory…](https://mymerci.kr/pages/nclex_q.php?qn_id=543256) - [A newborn delivered at 38 weeks gestation is experiencing meconium aspiration syndrome. 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