# A newborn delivered at 40 weeks gestation appears cyanotic with poor muscle tone. The heart rate is 80 beats per minute, there is no respiratory effort, and the infant does not respond to stimulation. What is the nurse's priority action?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543193  
> language: ko  
> subject: Maternal Newborn Health

## 문제

A newborn delivered at 40 weeks gestation appears cyanotic with poor muscle tone. The heart rate is 80 beats per minute, there is no respiratory effort, and the infant does not respond to stimulation. What is the nurse's priority action?

## 보기

1. Administer supplemental oxygen via face mask
2. Perform chest compressions at a rate of 120 per minute
3. Provide positive pressure ventilation with bag-mask device **✔ 정답**
4. Suction the airway and stimulate the infant

**정답: 3**

## 해설

No respiratory effort and bradycardia (HR 80) require immediate PPV per neonatal resuscitation guidelines. Other interventions (oxygen, compressions, suction) are secondary until ventilation is established.

## 심화 해설

Clinical Scenario Analysis

The newborn presents with the classic triad of neonatal resuscitation triggers: cyanosis, poor muscle tone, and a heart rate of 80 beats per minute. This heart rate is below the critical threshold of 100 bpm, which defines bradycardia in newborns. The absence of respiratory effort and unresponsiveness to stimulation confirm that this infant is in a state of secondary apnea and requires immediate ventilatory support, not just tactile stimulation or supplemental oxygen.

Pathophysiology and Mechanism

In the transition from fetal to neonatal circulation, the most critical physiological event is lung aeration and the establishment of functional residual capacity. When a newborn fails to initiate effective respirations, the alveoli remain fluid-filled, preventing gas exchange. This leads to progressive hypoxemia and acidosis, which directly depress the myocardium, causing bradycardia. The heart rate of 80 bpm is a direct consequence of myocardial hypoxia, not a primary cardiac event. Therefore, the most effective way to increase heart rate is to reverse the hypoxia by aerating the lungs. Administering positive pressure ventilation (PPV) addresses the root cause by delivering oxygen to the alveoli, which then diffuses into the pulmonary capillaries, reversing the hypoxic myocardial depression and reflexively increasing the heart rate.

Why Not the Other Options

**Option 1 (Administer supplemental oxygen via face mask):** Supplemental oxygen delivered without positive pressure cannot aerate fluid-filled lungs. A non-breathing infant has no tidal volume, so blow-by or free-flow oxygen will not reach the alveoli for gas exchange. This intervention is insufficient for an apneic, bradycardic newborn.

**Option 2 (Perform chest compressions):** Chest compressions are indicated when the heart rate remains below 60 bpm despite at least 30 seconds of effective PPV that adequately ventilates the lungs. Since ventilation has not yet been provided, initiating compressions first would delay the most critical intervention. The bradycardia here is respiratory in origin, and compressions without first establishing ventilation are ineffective.

**Option 4 (Suction the airway and stimulate the infant):** Routine suctioning is no longer recommended for vigorous or non-vigorous newborns unless there is obvious obstruction or meconium with airway blockage. The infant has already failed to respond to stimulation, as noted in the scenario. A recent observational study highlighted that while tactile stimulation is the recommended first step for non-breathing newborns, the presence of bradycardia (

## 임상 시나리오

Clinical Practice Guide: Initial Steps in Neonatal Resuscitation

The Neonatal Resuscitation Program (NRP) algorithm provides a systematic approach to the compromised newborn. The most critical initial assessment occurs within the first 30 to 60 seconds after birth, evaluating tone, respiratory effort, and heart rate.

- **Rapid Assessment:** At delivery, ask three questions: Is the baby term? Is the baby breathing or crying? Is there good muscle tone? If the answer to any is "no," proceed to initial steps of warming, positioning, clearing the airway, drying, and stimulating.

- **Heart Rate as Decision Point:** After initial steps, reassess heart rate. A heart rate below 100 bpm, even with some respiratory effort, is the key trigger to initiate positive pressure ventilation (PPV). Auscultation of the apical pulse or palpation of the umbilical cord base provides the most accurate count.

- **Ventilation First, Not Chest Compressions:** Bradycardia in the newborn is almost always caused by hypoxia. Effective lung inflation is the single most important intervention. Chest compressions are only indicated if the heart rate remains below 60 bpm despite at least 30 seconds of effective PPV that inflates the lungs.

- **Monitoring Effectiveness:** The primary measure of adequate PPV is a rapidly increasing heart rate. Observe for chest rise and auscultate bilateral breath sounds. If heart rate does not improve, use the MR. SOPA mnemonic to correct ventilation: Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase, Airway alternative.

## 핵심 개념

- **Positive Pressure Ventilation (PPV)** — Delivery of breaths via bag-mask device to inflate the lungs and establish gas exchange in a non-breathing newborn.
- **Neonatal Resuscitation Program (NRP) Algorithm** — A standardized sequence of interventions beginning with warming, drying, stimulating, and progressing to PPV if the newborn is apneic or heart rate is below 100 bpm.
- **Secondary Apnea** — A state of respiratory arrest following a period of gasping, requiring assisted ventilation to reverse hypoxemia and acidosis.
- **Functional Residual Capacity** — The volume of air remaining in the lungs after a normal expiration, which must be established at birth through lung aeration.

## 같은 주제 문제

- [A nurse is assessing a newborn immediately after delivery. Which assessment finding would …](https://mymerci.kr/pages/nclex_q.php?qn_id=543186)
- [A nurse is performing the initial assessment of a newborn immediately after delivery. Whic…](https://mymerci.kr/pages/nclex_q.php?qn_id=543187)
- [A newborn delivered at 38 weeks gestation is brought to the nursery. The nurse notes the i…](https://mymerci.kr/pages/nclex_q.php?qn_id=543188)
- [A newborn delivered at 38 weeks gestation is brought to the nursery. The nurse notes the i…](https://mymerci.kr/pages/nclex_q.php?qn_id=543189)
- [A full-term newborn is delivered vaginally after an uncomplicated labor. The infant appear…](https://mymerci.kr/pages/nclex_q.php?qn_id=543190)
- [A newborn delivered at 40 weeks gestation appears cyanotic with poor muscle tone. The hear…](https://mymerci.kr/pages/nclex_q.php?qn_id=543191)
- [A newborn delivered at 38 weeks gestation is brought to the nursery. The nurse notes the i…](https://mymerci.kr/pages/nclex_q.php?qn_id=543192)
- [A newborn delivered at 36 weeks gestation appears pale with decreased muscle tone. The hea…](https://mymerci.kr/pages/nclex_q.php?qn_id=543194)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._