Page 828 - Saunders Comprehensive Review For NCLEX-RN

A. Description: Serious lung disorder caused by immaturity and
inability to produce surfactant, resulting in hypoxia and acidosis
B. Assessment
1. Respiratory distress; can include tachypnea, nasal
flaring, expiratory grunting, retractions, seesaw
respirations, decreased breath sounds, and apnea
2. Pallor and cyanosis
3. Hypothermia
4. Poor muscle tone
C. Interventions
1. Monitor color, respiratory rate, and degree of effort in
breathing.
2. Maintain airway and cardiopulmonary function and
support respirations as prescribed.
3. Monitor arterial blood gases and oxygen saturation
levels as prescribed (arterial blood gases from
umbilical artery); ensure that oxygen administered to
the newborn is at the lowest possible concentration
necessary to maintain adequate arterial oxygenation.
4. Any premature newborn who required oxygen
support should be scheduled for an eye examination
before discharge to assess for retinal damage.
5. Position the newborn on the side or back, with the
neck slightly extended.
6. Administer respiratory therapy (percussion and
vibration) as prescribed; use padded small plastic cup
or small oxygen mask for percussion; use padded
electric toothbrush for vibration.
7. Provide nutrition.
8. Support bonding.
9. Prepare parents for short-term to long-term period of
oxygen dependency if necessary.
10. Encourage the mother to pump the breasts for future
breast-feeding of her newborn if she desires.
11. Encourage as much parental participation in the
newborn’s care as the condition allows.

Prepare to administer surfactant replacement therapy (instilled

into the endotracheal tube) to a newborn with respiratory distress
syndrome.
XI. Meconium Aspiration Syndrome
A. Description
1. Occurs in term or postterm newborns
2. Exact etiology is unknown, but the release of
meconium into the amniotic fluid is thought to be
related to a stressful fetal event initiating a
biochemical chain of events.

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