# A nurse is caring for a 2-hour-old newborn in the nursery. The infant appears pink with some acrocyanosis, has a strong cry, and shows good muscle tone. Which action should the nurse prioritize first to ensure the newborn's safety and prevent complications? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543196 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is caring for a 2-hour-old newborn in the nursery. The infant appears pink with some acrocyanosis, has a strong cry, and shows good muscle tone. Which action should the nurse prioritize first to ensure the newborn's safety and prevent complications? A full-term newborn has just been delivered vaginally. The infant appears pink with some acrocyanosis, has a strong cry, and shows good muscle tone. The umbilical cord is still attached and pulsating. ## 보기 1. Perform immediate umbilical cord clamping and cutting 2. Administer vitamin K injection within the first hour 3. Begin breastfeeding initiation within 30 minutes 4. Clear the airway and establish effective breathing **✔ 정답** **정답: 4** ## 해설 Clearing the airway and establishing breathing is the priority per ABCs of emergency care, as respiratory adaptation is critical after birth. Other actions are important but secondary. ## 심화 해설 Understanding the Immediate Transition to Extrauterine Life The first moments after birth represent the most dramatic physiological transition a human will ever experience. While the newborn in this scenario appears vigorous—pink with acrocyanosis, a strong cry, and good muscle tone—the priority action remains ensuring the establishment of a stable airway and effective respirations. The transition from fetal to neonatal circulation is triggered by the newborn's first breaths, which expand the lungs, decrease pulmonary vascular resistance, and facilitate the closure of the foramen ovale and ductus arteriosus. A delay or failure in this process can lead to persistent pulmonary hypertension and hypoxia, even in an infant who initially appears well. The presence of a pulsating umbilical cord indicates that the placental transfusion is still in progress, a physiological benefit of delayed cord clamping, but it does not supersede the immediate need to confirm respiratory stability. Clearing the airway of secretions and ensuring the infant is breathing effectively is the foundational step of neonatal resuscitation and stabilization, as outlined by the Neonatal Resuscitation Program (NRP) algorithm, which always begins with airway positioning, clearing secretions if needed, and stimulating breathing. Analyzing the Options Through a Priority-Setting Lens In NCLEX-RN priority questions, the nurse must apply the ABC (Airway, Breathing, Circulation) framework. A 2-hour-old newborn with a strong cry and good tone has already demonstrated effective breathing; however, the question asks for the priority action "to ensure the newborn's safety and prevent complications" immediately after a vaginal delivery with the cord still pulsating. This timing places the nurse at the moment of transition, where the airway and breathing are the most time-critical elements. - Option 1: Perform immediate umbilical cord clamping and cutting. This action is not a priority and may be contraindicated. Current evidence supports delayed cord clamping (for at least 30–60 seconds) in vigorous term infants to allow for placental transfusion, which increases iron stores and improves hemodynamic stability. Immediate clamping is reserved for situations where the infant requires advanced resuscitation away from the mother. - Option 2: Administer vitamin K injection within the first hour. While this is a critical preventive measure to prevent vitamin K deficiency bleeding (VKDB), it is not the first priority. The injection is typically administered after the initial stabilization, bonding, and breastfeeding initiation, usually within the first 6 hours of life. It addresses a hematologic risk that develops over days, not an immediate cardiorespiratory threat. - Option 3: Begin breastfeeding initiation within 30 minutes. Early initiation of breastfeeding is a key component of newborn care, promoting bonding, thermoregulation, and glucose stability. However, a successful latch and feeding are secondary to confirming that the infant has a patent airway and is effectively oxygenating. A neurologically depressed or hypoxic infant will not feed effectively. - Option 4: Clear the airway and establish effective breathing. This is the correct priority. The sequence of initial newborn care begins with drying, stimulating, and positioning the infant, followed by suctioning the mouth and then the nose if excessive secretions are present. The nurse must assess the respiratory effort, heart rate, and color to confirm successful transition. Even a vigorous infant can develop respiratory distress from retained lung fluid (transient tachypnea of the newborn) or meconium aspiration, making airway and breathing assessment the non-negotiable first step. Connecting Clinical Presentation to Underlying Physiology The infant's presentation—pink with acrocyanosis—is a normal finding in the immediate newborn period. Acrocyanosis, the bluish discoloration of the hands and feet, results from vasomotor instability and sluggish peripheral circulation, not from central hypoxia. This distinguishes it from central cyanosis, which involves the trunk and mucous membranes and indicates a true oxygenation deficit. The strong cry and good muscle tone are reassuring signs of a vigorous central nervous system and adequate oxygenation. However, the nurse cannot assume continued stability without first performing a focused respiratory assessment. The pulsating umbilical cord signifies that the umbilical arteries and vein are still patent, allowing for ongoing transfer of oxygenated blood from the placenta. Once the cord stops pulsating and is clamped, the infant must rely entirely on its own lungs for gas exchange. The nurse's immediate role is to ensure that this independent respiratory effort is adequate, which is achieved by clearing the airway and positioning the infant to facilitate unobstructed breathing. This action directly prevents complications such as hypoxemia, respiratory acidosis, and the potential need for positive-pressure ventilation. ## 임상 시나리오 Clinical Practice Guide: Immediate Newborn Stabilization Initial Assessment and Airway Management - Place the newborn under a radiant warmer, dry thoroughly, and remove wet linens to prevent heat loss. - Position the infant supine with the neck in a neutral or slightly extended ("sniffing") position to open the airway. - Suction the mouth first, then the nares with a bulb syringe or suction catheter to clear secretions, only if the airway is obstructed or respirations are depressed. - Assess respiratory effort, heart rate, and color simultaneously. A strong cry and good muscle tone indicate effective ventilation. Transitional Physiology and Cord Management - Recognize that acrocyanosis is a normal finding in the first hours after birth and does not require supplemental oxygen. - Support delayed cord clamping (at least 30-60 seconds) for vigorous term newborns to enhance placental transfusion, unless contraindicated. - Monitor the cord; pulsations will cease naturally as the umbilical arteries constrict. Avoid immediate clamping in the absence of a medical indication. Ongoing Care and Prevention - Once respiratory stability is confirmed, facilitate skin-to-skin contact and early breastfeeding within the first hour to promote thermoregulation and bonding. - Administer intramuscular vitamin K (1 mg) within 6 hours of birth to prevent vitamin K deficiency bleeding. - Apply erythromycin ophthalmic ointment to prevent gonococcal ophthalmia neonatorum per facility protocol. ## 핵심 개념 - **Acrocyanosis** — Bluish discoloration of the hands and feet, a common and normal finding in newborns shortly after birth due to vasomotor instability and sluggish peripheral circulation. - **Delayed Cord Clamping** — Waiting 30-60 seconds after birth to clamp the umbilical cord, allowing placental blood to transfuse to the newborn, which improves iron stores and circulatory transition. - **Neonatal Resuscitation Program (NRP)** — An evidence-based algorithm for newborn stabilization that prioritizes airway positioning, clearing secretions, and stimulating breathing as the initial steps. - **Foramen Ovale** — An opening between the right and left atria in the fetal heart that normally closes shortly after birth as pulmonary blood flow increases and left atrial pressure rises. ## 같은 주제 문제 - [A nurse is assessing a newborn immediately after delivery. 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