A nurse is caring for a preterm infant. Which finding(s) would indicate the need for further action? (Select all that apply.)
a. Nasal flaring
b. Cyanosis
c. Expiratory grunt
d. Irregular respiratory rate
e. Five-second periods of apnea
f. Substernal chest retractions
ANS: A, B, C, F
Nasal flaring, substernal (chest) retractions, cyanosis, tachypnea, expiratory grunt, and see-saw respirations are classic signs of respiratory distress. Brief periods of apnea and irregular respirations are not abnormal in the newborn.
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