A newborn delivered at 38 weeks gestation is brought to the nursery. The nurse notes the infant has a heart rate of 110 bpm, weak cry, some flexion of extremities, grimaces to suction, and pink body with blue hands and feet. What is the nurse's priority action?

The newborn's weak cry, bradycardia, and poor tone indicate respiratory depression requiring immediate positive pressure ventilation (PPV). Other options (documenting, warming, oxygen) are insufficient for inadequate ventilation.

Clinical Judgment This question assesses the ability to evaluate a newborn's immediate condition and determine the priority intervention. The key is not memorizing the APGAR score, but grasping what picture the presented clinical signs collectively paint, and what immediate danger that picture signifies. The newborn exhibits a "weak cry" and a "heart rate at the lower limit of normal (110 bpm)." This indicates ineffective spontaneous breathing, posing a risk of progression to hypoxia and secondary bradycardia. "Blue hands and feet (pink body with blue hands and feet)" is physiological acrocyanosis, which can be normal immediately after birth, but becomes a warning sign when accompanied by other signs of depression. Therefore, the nurse's top priority goal is to establish effective lung ventilation. The bag-mask positive-pressure ventilation in option 3 is the primary intervention for a newborn with inadequate respiratory effort to expand the lungs and improve oxygenation. Memory Tip: Remember the newborn resuscitation Algorithm: Airway, Breathing, Circulation. A "weak cry" signifies failure at the Breathing step. A "heart rate of 110" is not yet a Circulation problem, but it can quickly become one if breathing does not improve. Therefore, the intervention must begin with Breathing. KR vs US: In both Korea and the US, the Neonatal Resuscitation Program (NRP) algorithm is internationally standardized, so there is no significant difference. However, in NGN/NCLEX questions asking for the "Priority Action," an evidence-based algorithmic approach is heavily emphasized. Rather than calling a supervisor or charting, you must select the intervention the nurse can immediately initiate according to the algorithm.

Clinical Practice Guide During the initial assessment of a newborn, the APGAR score is a standardized tool checked at 1 and 5 minutes, but the nurse must perform continuous clinical assessment even while calculating the score. Signs such as "weak cry" or "absent reflex to suctioning" are signals that demand immediate action before being scored. After initiating positive pressure ventilation, the heart rate (auscultation or palpation of the umbilical pulse) must be reassessed within 30 seconds to determine the effectiveness of the intervention. Caution: In SATA (Select All That Apply) questions asking about interventions for "cyanosis in a newborn," distinguishing between central cyanosis (blue lips, tongue) and acrocyanosis (blue only in hands and feet) is a key trap point. Central cyanosis requires immediate reporting and initiation of resuscitation, whereas acrocyanosis in the first few hours after birth can often be observed. In this question, note that acrocyanosis is present but combines with other vital signs to form the overall picture.