A nurse is caring for a newborn immediately after delivery. Which action should the nurse prioritize first to ensure the newborn's safety and prevent complications?

Establishing a clear airway is the highest priority (ABCs) to ensure oxygenation, as other interventions like vitamin K, identification, or delayed cord clamping can wait until breathing is effective.

Clinical Reasoning and Prioritization

The correct answer is to clear the airway and establish effective breathing. In the immediate care of a newborn, the highest priority is always the establishment of a patent airway and effective ventilation. This principle is rooted in the foundational resuscitation sequence, which prioritizes airway (A) and breathing (B) before circulation (C) or other interventions. The transition from fetal to neonatal life is a critical physiological event where the newborn must rapidly clear fetal lung fluid and initiate air breathing to facilitate gas exchange. Failure to do so leads to hypoxia, the most common and immediate threat to a newborn's survival and long-term neurological outcome.

The provided 2025 Korean CPR guidelines ^[1] reinforce this systematic approach. While the abstract focuses on the guideline update process, it inherently validates the structured, evidence-based sequence of resuscitation, which begins with airway and breathing support. This is the universally accepted standard of care. The study on sustained lung inflation (SI) ^[2] further underscores the primacy of respiratory support in the delivery room. This randomized controlled trial investigated an advanced airway technique for preterm infants showing signs of respiratory distress, even those not initially requiring positive pressure ventilation. The very existence of this research highlights that the clinical focus in the first minutes of life is on optimizing lung aeration and respiratory function to prevent downstream morbidities and mortality. The intervention is centered on the "B" step of the ABCs, confirming that respiratory management is the immediate clinical priority.

Other actions, while important, are secondary to establishing ventilation. Administering vitamin K, applying identification bands, and clamping the cord are all time-sensitive but not immediately life-preserving. A newborn who is not breathing will not benefit from these interventions. The physiological basis for airway clearance is also supported by the research on mucociliary transport and mucus homeostasis . These studies explain the mechanism by which the airway clears fluid and particles. At birth, the newborn's airway must transition from a fluid-filled to an air-filled state. Effective clearance of this fluid, driven by mechanisms like mucociliary transport which is influenced by particle (or fluid) size and a balanced mucus gel layer composed of MUC5AC and MUC5B , is essential for successful air entry. The nurse's initial action of positioning the infant, suctioning the mouth and then the nose, and providing tactile stimulation directly supports these physiological clearance mechanisms to establish the first breath.