The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborn's diaper, the nurse observes the newborn's color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:

A) stress.
B) subtle seizures.
C) preterm behavior.
D) onset of respiratory distress.

Question

Ibrahim Khanat · Accepted Answer

Final Answer : A, Explanation :  Color pink but slightly mottled, arms and legs limp and extended, hiccups, respiratory pauses and gasping, and an irregular, rapid heart rate are signs of stress or fatigue in a newborn. Neonatal seizures usually have some type of repetitive movement from twitching to rhythmic jerking movements. The behavior of a preterm newborn may be inactive and listless. Respiratory distress is exhibited by retractions and nasal flaring.

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