Nursing care
Respiratory Distress Syndrome nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated September 2026
Short answer
Respiratory distress syndrome in the preterm infant is caused by surfactant deficiency, and the earliest signs are grunting and nasal flaring, not cyanosis. Nursing priority is airway and oxygenation support, close respiratory monitoring, and surfactant administration where ordered. Delay in recognising early signs allows alveolar collapse to progress before intervention starts.
The clinical picture
Respiratory distress syndrome develops when a preterm infant's lungs cannot produce enough surfactant to keep alveoli open at end-expiration. Without surfactant, surface tension collapses the alveoli, gas exchange falls, and the infant works progressively harder to breathe. Onset is typically within minutes to hours of birth and worsens over the first 24 to 48 hours if untreated.
Risk rises sharply with prematurity, particularly below 34 weeks' gestation, and further with maternal diabetes, caesarean delivery without labour, and perinatal asphyxia. The infant who looks stable at delivery can deteriorate fast once transitional circulation shifts demand onto immature lungs. Nurses caring for any preterm delivery should expect this trajectory rather than wait for overt distress to appear.
Assessment: what to look for and in what order
Grunting and nasal flaring are the earliest signs and should trigger immediate escalation, not observation. Grunting is the infant's own attempt to maintain positive end-expiratory pressure by exhaling against a partially closed glottis; nasal flaring reflects the drive to reduce airway resistance. Both precede the more obvious signs nurses are taught to expect first.
After grunting and flaring, assess for intercostal and subcostal retractions, tachypnoea above 60 breaths per minute, and see-saw chest-abdomen movement. Cyanosis and falling oxygen saturation are late findings and should not be the trigger for first action. Auscultate for diminished breath sounds and fine crackles, and correlate with continuous pulse oximetry and, where available, transcutaneous or arterial blood gas monitoring for rising CO2 and falling pH.
Immediate interventions
On recognising grunting or flaring, position the infant to optimise airway patency, initiate or increase supplemental oxygen or CPAP as ordered, and notify the neonatal team without delay. Continuous positive airway pressure is frequently the first-line respiratory support and works by splinting alveoli open, directly compensating for the missing surfactant.
Where ordered, prepare for exogenous surfactant administration via endotracheal tube, and anticipate that intubation and mechanical ventilation may follow if CPAP fails to maintain adequate gas exchange. Maintain thermoregulation throughout, since cold stress increases oxygen consumption and worsens respiratory effort. Minimise handling and cluster care to reduce oxygen demand during the acute phase.
Ongoing nursing management
Continuous monitoring of respiratory rate, work of breathing, oxygen saturation, and blood gases guides ventilator or CPAP adjustments. Watch for signs of pneumothorax, a known complication of both the disease process and positive pressure support, including sudden deterioration, asymmetric chest movement, and muffled heart sounds.
Maintain strict fluid balance, as fluid overload worsens pulmonary oedema while under-hydration compromises perfusion. Support nutrition, typically via parenteral or trophic feeds until respiratory status stabilises, and protect skin integrity given the prolonged positioning and adhesive use that respiratory support requires. Track weaning readiness daily rather than waiting for a scheduled review, since prolonged unnecessary ventilation carries its own risks.
Patient and family education
Parents need a clear, honest explanation that respiratory distress syndrome is a lung maturity issue, not something they caused, and that many infants improve steadily once surfactant is administered and support is in place. Explain the purpose of each piece of equipment before the parents' first visit to the incubator, since unexplained tubing and monitors are a common source of fear.
Encourage kangaroo care and parental touch as soon as the infant's condition allows, and involve parents in feeding and comfort measures as respiratory support is weaned. Discuss discharge expectations early, including that some infants go home on supplemental oxygen and that follow-up respiratory assessment continues after discharge.
How this appears on the NCLEX
Questions on this topic typically test whether the candidate recognises grunting and nasal flaring as the earliest, priority findings rather than choosing cyanosis or apnoea as the answer. Expect scenario stems describing a preterm infant shortly after birth, with several respiratory findings listed, asking which finding requires immediate action.
Other common angles include selecting CPAP or surfactant administration as the priority intervention over supportive measures, and identifying pneumothorax as a complication to monitor for once ventilatory support begins. Distractor options often include correct but lower-priority nursing actions, so apply the same first-versus-right logic used across NCLEX priority items.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our maternity and newborn practice questions are the closest set to what this page covers.
Common questions
What is the first sign of respiratory distress syndrome in a newborn?
Grunting and nasal flaring appear first, before retractions, tachypnoea, or cyanosis. These reflect the infant's own compensatory effort to keep alveoli open and should prompt immediate assessment and escalation rather than a wait-and-see approach.
Why does surfactant deficiency cause respiratory distress?
Surfactant reduces surface tension in the alveoli, keeping them open at the end of expiration. Preterm infants who have not yet produced adequate surfactant experience alveolar collapse with each breath, which increases the work of breathing and impairs gas exchange.
What is the priority nursing intervention for RDS?
Support oxygenation and ventilation, typically starting with CPAP, and notify the neonatal team promptly when early signs appear. Prepare for surfactant administration if ordered, since this addresses the underlying deficiency rather than only the symptoms.
Which complication should nurses watch for during CPAP or ventilation?
Pneumothorax is a key complication of both the underlying lung disease and positive pressure support. Sudden deterioration, asymmetric chest movement, or muffled heart sounds warrant immediate reassessment.
How is RDS different from other causes of newborn breathing difficulty?
RDS is specifically caused by surfactant deficiency in preterm infants and follows a predictable worsening course over the first 24 to 48 hours without treatment. Other causes of newborn respiratory distress, such as transient tachypnoea or meconium aspiration, have different mechanisms and timelines, though initial assessment findings can overlap.