RN Nursing · Newborn Complications — Respiratory Distress · Practice question
A nurse is assessing a newborn 15 minutes after birth and observes a respiratory rate of 70 breaths per minute accompanied by nasal flaring and intercostal retractions. The newborn’s skin shows cyanosis around the mouth. What is the nurse’s priority action?
-
Administer a dose of prophylactic antibiotics to prevent infection causing respiratory distress.
-
Encourage the mother to breastfeed immediately to improve oxygenation and respiratory effort.
-
Continue monitoring the newborn as these signs are common transitional findings and usually resolve within a few hours.
-
✓
Notify the healthcare provider immediately and prepare for potential respiratory support.
Answer & explanation
Correct: Notify the healthcare provider immediately and prepare for potential respiratory support.
A respiratory rate of 70 breaths per minute, nasal flaring, intercostal retractions, and perioral cyanosis in a newborn 15 minutes after birth indicate respiratory distress that exceeds normal transitional findings. While some mild tachypnea and acrocyanosis can be seen in the first few minutes after birth, persistent perioral cyanosis combined with signs of increased work of breathing — nasal flaring and intercostal retractions — are abnormal and require immediate provider notification and preparation for respiratory support such as supplemental oxygen, CPAP, or bag-mask ventilation. These findings may indicate conditions such as transient tachypnea of the newborn, respiratory distress syndrome, meconium aspiration syndrome, or a cardiac anomaly. Administering prophylactic antibiotics is not the priority because respiratory support takes precedence over infection prevention in this acute scenario. Breastfeeding is contraindicated when a newborn is in respiratory distress, as the infant cannot safely coordinate sucking, swallowing, and breathing. Continuing to monitor without intervention is inappropriate given the severity and combination of signs — waiting could lead to rapid deterioration. The priority is always to secure the airway and ensure adequate oxygenation, making immediate provider notification and preparation for respiratory support the correct and safest response.
Practise Newborn Complications — Respiratory Distress questions
Work through full question sets with instant rationales, timed exams, and progress tracking.
Start practising freeRelated practice questions
- A practical nurse is caring for a newborn who is 30 mins old. Select 1 condition and 1 client finding to fill in each blank in the following sentence. The newborn has the greatest risk for developing ____ due to ____.
- A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse?
- A nurse is caring for a newborn. Select words from the choices below to fill in each blank in the following sentence. The nurse should further evaluate ____, ____ and ____ to determine if the newborn is experiencing a complication.
- What are the nursing actions to take when caring for a newborn diagnosed with meconium aspiration syndrome? Select all that apply.