# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543192  
> language: ko  
> subject: Maternal Newborn Health

## 문제

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?

## 보기

1. Document the findings and continue routine newborn care
2. Place the infant under a radiant warmer and monitor vital signs
3. Begin positive pressure ventilation with bag-mask ventilation **✔ 정답**
4. Administer supplemental oxygen via nasal cannula

**정답: 3**

## 해설

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.

## 심화 해설

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 **A**lgorithm: **A**irway, **B**reathing, **C**irculation. A "weak cry" signifies failure at the **B**reathing step. A "heart rate of 110" is not yet a **C**irculation problem, but it can quickly become one if breathing does not improve. Therefore, the intervention must begin with **B**reathing.

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.

## 임상 시나리오

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.

## 핵심 개념

- **APGAR Score** — A standardized tool for quickly assessing a newborn's condition at 1 and 5 minutes after birth. It stands for Appearance (color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing).
- **Positive Pressure Ventilation** — A resuscitation technique that uses a bag and mask to blow positive-pressure air (or oxygen) into the lungs to assist or replace breathing. It is the primary intervention for newborns with absent or insufficient effective spontaneous breathing.
- **Acrocyanosis** — Physiological acrocyanosis. A normal phenomenon where the hands and feet appear bluish during the first 24-48 hours after birth. The central part of the body remains pink.
- **Respiratory Depression** — Breathing is suppressed, resulting in insufficient frequency, depth, or effectiveness. In newborns, it presents with weak crying, irregular breathing, bradycardia, etc.
- **Neonatal Resuscitation** — A series of interventions performed on a newborn who has failed to transition to extrauterine life. It consists of the following steps: airway maintenance, breathing support (positive pressure ventilation), circulation support (chest compressions), and medication administration.

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