# A 3-day-old newborn is admitted to the neonatal intensive care unit with suspected sepsis. The infant presents with temperature instability, poor feeding, lethargy, and mottled skin. Which nursing assessment finding would be the highest priority to report immediately to the healthcare provider?

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> subject: Maternal Newborn Health

## 문제

A 3-day-old newborn is admitted to the neonatal intensive care unit with suspected sepsis. The infant presents with temperature instability, poor feeding, lethargy, and mottled skin. Which nursing assessment finding would be the highest priority to report immediately to the healthcare provider?

## 보기

1. Axillary temperature of 97.2°F (36.2°C) with mottled skin
2. Heart rate of 180 beats per minute with poor feeding
3. Respiratory rate of 70 breaths per minute with grunting and nasal flaring **✔ 정답**
4. Blood glucose level of 65 mg/dL with lethargy

**정답: 3**

## 해설

Respiratory distress with tachypnea, grunting, and nasal flaring indicates severe compromise and potential respiratory failure, requiring immediate intervention. Other findings like temperature instability, tachycardia, or normal glucose are less urgent in sepsis.

## 심화 해설

Clinical Reasoning and Priority Setting

This question tests your ability to apply the ABC (Airway, Breathing, Circulation) priority-setting framework within the high-acuity context of neonatal sepsis. While all options represent concerning findings, you must identify the assessment data that signals an immediate, life-threatening compromise requiring urgent intervention.

Analysis of the Correct Answer

Option 3: Respiratory rate of 70 breaths per minute with grunting and nasal flaring.

This is the highest priority finding. In a neonate with suspected sepsis, a respiratory rate of 70 breaths per minute accompanied by grunting and nasal flaring indicates severe respiratory distress and impending respiratory failure. Grunting is a physiological attempt to generate positive end-expiratory pressure (PEEP) by exhaling against a partially closed glottis, which prevents alveolar collapse. Nasal flaring decreases airway resistance and increases the diameter of the nares to maximize airflow. These are classic, late signs of significant pulmonary compromise, often associated with pneumonia, sepsis-induced acute respiratory distress syndrome (ARDS), or metabolic acidosis. A systematic review and meta-analysis examining clinical signs in young infants found that respiratory distress signs, including grunting, are strongly associated with both sepsis and mortality [1]. Because airway and breathing are the first priorities in the ABC framework, this finding must be reported immediately to prevent respiratory arrest.

Analysis of Incorrect Options

Option 1: Axillary temperature of 97.2°F (36.2°C) with mottled skin.

Temperature instability is a hallmark sign of neonatal sepsis, and hypothermia is a more ominous sign than fever in this population, often reflecting the body's inability to mount a compensatory response. Mottled skin indicates poor peripheral perfusion and circulatory compromise. While these findings are highly concerning and represent a "circulation" problem, they do not take priority over an immediate "breathing" compromise. The meta-analysis confirms that hypothermia is a significant predictor of mortality, but the presence of active respiratory distress with increased work of breathing takes precedence in the moment of assessment [1].

Option 2: Heart rate of 180 beats per minute with poor feeding.

Tachycardia is a compensatory mechanism for hypoxemia, hypovolemia, or fever. A heart rate of 180 bpm is at the upper limit of normal for a neonate and warrants close monitoring. Poor feeding is a sensitive but nonspecific sign of systemic illness, often representing lethargy and energy conservation. While this combination of "circulation" and neurologic/behavioral signs requires intervention, it is not as immediately life-threatening as the active respiratory distress described in Option 3. The provider must be notified, but the report of grunting and nasal flaring should be verbalized first.

Option 4: Blood glucose level of 65 mg/dL with lethargy.

A blood glucose of 65 mg/dL is within the normal range for a neonate and does not represent hypoglycemia requiring emergent correction. Lethargy is a significant neurologic sign in the context of suspected sepsis, as it can be a manifestation of poor cerebral perfusion or meningitis. However, the combination of a normal glucose value and a nonspecific neurologic sign does not signal an immediate crisis that trumps a severe "breathing" problem. The underlying cause of the lethargy is likely the sepsis itself, which is being addressed, but the immediate threat to the airway and breathing from respiratory distress demands the highest priority.

Pathophysiology and Clinical Integration

The clinical presentation of neonatal sepsis can be subtle and nonspecific, often mimicking other conditions. A case report on neonatal dengue highlights this diagnostic challenge, where an infant presented with early respiratory distress and thrombocytopenia, initially managed as bacterial sepsis before viral confirmation . This underscores a critical NCLEX-RN concept: your nursing assessment and prioritization are driven by the patient's physiological presentation, not the definitive diagnosis. The signs of respiratory distress—tachypnea, grunting, and nasal flaring—are objective indicators of a failing compensatory mechanism. The infant is expending excessive energy to maintain oxygenation and ventilation, a state that can rapidly progress to apnea and bradycardia. Your immediate role is to recognize this clinical deterioration, ensure airway patency and oxygen delivery, and communicate the most critical assessment findings to the provider without delay.References (research sources)

- [1]Clinical Signs Associated With Mortality and Sepsis in Young Infants: A Systematic Review and Meta-Analysis.Meta-analysis/systematic reviewDriker S, Mathias S, Fung A, Widyaningsih SA, Schmeck N, Adnan J, Kim Y, Hussaini AS, Kehoe T, North K, Hoey A, Shafiq Y, Wade CG, Mediratta RP, Rees CA, Lee AC. (2026) · DOI: 10.1001/jamapediatrics.2025.5967

## 임상 시나리오

Neonatal Sepsis: Recognizing Impending Respiratory FailurePrioritizing ABCs in the NICU
In a septic neonate, grunting and nasal flaring are late signs of severe respiratory distress and indicate impending respiratory failure. A respiratory rate > 60 breaths/min with these signs demands immediate intervention.

Grunting is the neonate's attempt to generate physiologic PEEP by exhaling against a partially closed glottis to keep alveoli open. Nasal flaring reduces airway resistance. These compensatory mechanisms signal exhaustion and the need for respiratory support.

CautionDo not delay reporting to address other findings like hypothermia or borderline glucose. Respiratory distress takes absolute priority in the ABC framework. Prepare for immediate provider notification and potential escalation to CPAP or intubation.

## 핵심 개념

- **Grunting** — An expiratory sound made against a partially closed glottis to generate physiologic PEEP and prevent alveolar collapse, a late sign of respiratory distress in neonates.
- **Nasal Flaring** — Widening of the nostrils during inspiration to decrease airway resistance and increase airflow, indicating significant respiratory effort.
- **ABC Framework** — A priority-setting model where Airway, Breathing, and Circulation are addressed in order, making respiratory distress the highest priority over circulatory or metabolic issues.

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