A neonate, 16 hours old, is in the NICU for respiratory distress. A chest X-Ray reveals heart failure. Lab results indicate: AB positive blood type, a positive Coomb’s test, serum bilirubin 16mg/dl, and severe anemia. The vital signs are 98.6 (F), HR 166, R 70. The infant is jaundiced from face to sole of feet and has generalized edema. What condition does the infant have?

Choice A rationale
Unlabored irregular respirations are not typically associated with respiratory distress in a neonate. In fact, newborns naturally have irregular breathing patterns, which can range from fast and shallow to slow and deep.
Choice B rationale
Grunting is a common symptom of respiratory distress in neonates. This is an involuntary noise that a baby makes when exhaling. It’s the baby’s attempt to keep air in the lungs to help them stay open and filled with air.
Choice C rationale
While apneic periods (pauses in breathing) can occur in neonates, a 5-second pause is within the normal range. Apnea of concern in neonates, particularly those with respiratory distress, is usually defined as cessation of breathing for 20 seconds or longer, or a shorter pause if it is accompanied by a slow heart rate or low oxygen levels.
Choice D rationale
Nasal flaring, where the nostrils spread open during breathing, is another common sign of respiratory distress in neonates. It’s an indication that the baby is having to work harder to breathe.
Choice E rationale
Use of accessory muscles is a sign of respiratory distress in neonates. This means the baby is using additional muscles (other than the diaphragm and chest muscles) to breathe. This can be seen as indrawing or retractions, where the skin pulls in between the ribs or the neck sinks in with each breath.

Choice A rationale
Informing the obstetrician is important, but it is not the first action to take. The nurse should first try to address the issue at hand, which is a displaced and boggy uterus.
Choice B rationale
Straight catheterization of the patient could be necessary if the patient is unable to void. However, the first step should be to ask the patient to void.
Choice C rationale
Preparing the patient for manual removal of uterine clots is a more invasive procedure that should be considered if other measures, such as asking the patient to void or massaging the fundus, are not effective.
Choice D rationale
A full bladder can displace the uterus and prevent it from contracting properly. Asking the patient to void can help the uterus contract and reduce bleeding.