While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply.)

Question

A) Grunting
B) Nasal flaring
C) Intercostal retractions
D) Oxygen saturation 96%
E) Increasing respiratory rate

Answer 1

A, B, C, E
Feedback:
A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions, which reflect the degree of difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits and does not indicate respiratory distress.