# A nurse is conducting an initial physical examination of a newborn immediately after delivery. Which assessment finding requires the most immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543199 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is conducting an initial physical examination of a newborn immediately after delivery. Which assessment finding requires the most immediate intervention? ## 보기 1. Acrocyanosis of the hands and feet 2. Central cyanosis of the lips and tongue **✔ 정답** 3. Vernix caseosa covering the skin 4. Molding of the head shape **정답: 2** ## 해설 Central cyanosis of the lips and tongue indicates inadequate oxygenation, requiring immediate intervention like oxygen administration and respiratory support. Acrocyanosis, vernix, and molding are normal newborn findings. ## 심화 해설 Understanding the Transition to Extrauterine Life Immediately after delivery, the newborn undergoes a dramatic physiological transition from fetal circulation to independent breathing. The initial physical examination focuses on evaluating the success of this transition, particularly the adequacy of ventilation and oxygenation. While many findings in a newborn can appear concerning, the nurse must rapidly distinguish between expected transitional adaptations and signs of true cardiorespiratory compromise. Analyzing the Assessment Findings The priority assessment framework dictates that airway, breathing, and circulation (ABCs) take precedence. In a newborn, the most critical indicator of effective breathing and circulation is adequate oxygenation, which is clinically assessed by skin color. - Central cyanosis (Option 2), observed on the lips, tongue, and central trunk, is a direct sign of hypoxemia. It indicates that the concentration of deoxygenated hemoglobin in the blood has reached a critical threshold, meaning the core organs and brain are not receiving sufficient oxygen. According to the 2025 Korean Guidelines for Neonatal Resuscitation, the primary focus immediately after birth is supporting the infant's respiratory and cardiovascular transition. Central cyanosis signals a failure of this transition and necessitates immediate intervention, such as airway clearance, tactile stimulation, and initiation of positive-pressure ventilation if the heart rate is low or breathing remains ineffective [1]. - Acrocyanosis (Option 1), the bluish discoloration of the hands and feet, is a normal and expected finding in the first hours after birth. It results from vasomotor instability and sluggish peripheral circulation, not from central hypoxemia. This finding does not require intervention beyond routine thermal care and ongoing observation. - Vernix caseosa (Option 3) is a protective, cheese-like substance covering the newborn's skin. It is a completely normal physiological finding that provides a moisture barrier and antimicrobial protection. Routine removal is no longer recommended, and its presence requires no intervention. - Molding (Option 4) is the temporary asymmetry of the skull bones resulting from the pressure exerted during vaginal delivery. The overriding of cranial sutures allows the head to pass through the birth canal. This is a benign, expected finding that resolves spontaneously over the first few days and requires no clinical intervention. Clinical Reasoning and Priority Setting The most immediate threat to life for a newborn is hypoxic-ischemic injury resulting from inadequate ventilation or perfusion. The 2025 neonatal resuscitation guidelines emphasize that the vast majority of newborns will successfully initiate spontaneous breathing, but the nurse must be prepared to rapidly identify the 10-15% who require assistance [1]. Central cyanosis is the most overt clinical sign of a failed cardiorespiratory transition and demands an immediate response to prevent progression to bradycardia and cardiorespiratory arrest. The other options represent normal variations of the newborn transition and require only documentation and continued monitoring.References (research sources) - [1]2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 9. Neonatal resuscitation.GuidelineHeo JS, Jung YH, Kim AE, Shim G, Cho SJ, Lee JH, Seol HJ, Lee GS, Oh AY, Myung HJ, Chung SP, Kim DK, Kim TY, Sohn Y, Oh Y, Youn CS, Lee MJ, Lee J, Lee CH, Jang Y, Jang YS, Cho GC, Cha KC, Hwang SO. (2026) · DOI: 10.15441/ceem.26.083 ## 임상 시나리오 Clinical Priority: Immediate Newborn Assessment When assessing a newborn immediately after delivery, the priority is to evaluate the success of the transition from fetal to neonatal circulation. The ABC (Airway, Breathing, Circulation) framework guides the nurse to first identify signs of inadequate oxygenation. **Critical Sign:** Central cyanosis (lips, tongue, trunk) is an ominous sign of hypoxemia. It indicates that the oxygen saturation is likely below 85% and the brain and vital organs are not being adequately perfused. This requires immediate intervention. **Immediate Nursing Actions for Central Cyanosis:** - Ensure a patent airway by positioning the infant in a "sniffing" position and suctioning the mouth then nose if secretions are present. - Provide tactile stimulation by drying the infant vigorously and flicking the soles of the feet. - If cyanosis persists, heart rate is less than 100 bpm, or respirations are gasping or absent, initiate positive-pressure ventilation (PPV) with 21% oxygen (room air) per neonatal resuscitation guidelines. - Attach a pulse oximeter to the right hand or wrist to obtain a preductal oxygen saturation reading and guide oxygen titration. - Notify the neonatal resuscitation team or provider immediately. **Differentiating from Benign Findings:** Acrocyanosis (bluish hands and feet only) is a normal finding caused by vasomotor instability and does not require intervention. Molding and vernix caseosa are also expected, non-emergent findings. ## 핵심 개념 - **Central Cyanosis** — A bluish discoloration of the lips, tongue, and trunk indicating hypoxemia and a critical decrease in arterial oxygen saturation requiring immediate intervention. - **Acrocyanosis** — Bluish discoloration of the hands and feet only, a normal finding in newborns due to vasomotor instability and sluggish peripheral circulation. - **Hypoxemia** — An abnormally low concentration of oxygen in the arterial blood, often first detected in newborns by the presence of central cyanosis. ## 같은 주제 문제 - [A nurse is conducting an initial physical examination of a newborn immediately after birth…](https://mymerci.kr/pages/nclex_q.php?qn_id=543198) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._