Home » NCLEX » NCLEX-RN » Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A newborn infant is exhibiting signs of respiratory distress. Which of the following would the nurse recognize as the earliest clinical sign of respiratory distress?
A. Cyanosis
B. Increased respirations
C. Sternal and subcostal retractions
D. Decreased respirations
Correct Answer: C
Explanation/Reference:
Explanation:
(A) Cyanosis is a late clinical sign of respiratory distress. (B) Rapid respirations are normal in a newborn. (C) The newborn has to exert an extra effort for ventilation, which is accomplished by using the accessory muscles of ventilation. The diaphragm and abdominal muscles are immature and weak in the newborn. (D) Decreased respirations are a late clinical sign. In the newborn, decreased respirations precede respiratory failure.
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