In neonatal RDS, surfactant deficiency causes high alveolar surface tension. Alveoli collapse at end-expiration, producing atelectasis, decreased lung compliance, reduced functional residual capacity, and ventilation-perfusion mismatch. The infant compensates with tachypnea, grunting, nasal flaring, retractions, and increased oxygen requirement. Grunting is a physiologic attempt to create auto-PEEP. By partially closing the glottis during expiration, the infant tries to keep alveoli open. Retractions occur because the infant must generate high negative intrathoracic pressure to inflate stiff, poorly compliant lungs. Hypoxemia occurs because collapsed alveoli are perfused but not adequately ventilated. If RDS worsens, the infant may develop respiratory acidosis, increasing oxygen and pressure requirements, apnea, fatigue, pneumothorax, pulmonary interstitial emphysema, and later bronchopulmonary dysplasia. The NP must recognize that delayed surfactant in a deteriorating preterm infant may prolong exposure to high oxygen and high pressure support. For Canadian NP practice / CNPLE-aligned preparation (Canada), items rarely announce the topic in the first sentence. Anchor to objective data, trajectory, and the safest next step for the role named in the stem before distractors compete. On the exam, writers often pair stable-sounding options...