A preterm infant of 33 weeks of gestation is admitted to the neonatal intensive care unit. Approximately 2 hours after birth, the neonate begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. What should the nurse recognize?
a. This is a normal finding.
b. Further evaluation is needed.
c. Improvement should occur within 24 hours.
d. This is not significant unless cyanosis is present.
ANS: B
These are signs of respiratory distress syndrome and require further evaluation. There is no way to predict the infant's clinical course based on the available data. Cyanosis may be present, but these are significant findings indicative of respiratory distress even without cyanosis.
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