# Situation: A 28-year-old woman at 40 weeks' gestation, who had one previous term vaginal birth, is in the second stage of labor at a lying-in clinic that follows the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol. Her first stage was uncomplicated, and the fetus is in a vertex presentation. Twenty minutes after birth, the healthy term baby is in skin-to-skin contact with the mother and has not yet fed. Mother and baby are both stable. A staff member wants to take the baby now to give eye ointment and vitamin K and to weigh the baby. Which response by the nurse is BEST according to the EINC protocol?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629381  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 28-year-old woman at 40 weeks' gestation, who had one previous term vaginal birth, is in the second stage of labor at a lying-in clinic that follows the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol. Her first stage was uncomplicated, and the fetus is in a vertex presentation.

Twenty minutes after birth, the healthy term baby is in skin-to-skin contact with the mother and has not yet fed. Mother and baby are both stable. A staff member wants to take the baby now to give eye ointment and vitamin K and to weigh the baby. Which response by the nurse is BEST according to the EINC protocol?

## 보기

1. Give the vitamin K now while the baby stays on the mother's chest
2. Weigh the baby quickly and return the baby within 5 minutes
3. Give the eye ointment now, since the baby is not yet feeding
4. Defer these until after the baby's first full breastfeed **✔ 정답**

**정답: 4**

## 해설

EINC keeps a stable mother and newborn together in uninterrupted skin-to-skin contact until the first full breastfeed. Babies often rest for 20 to 30 minutes or longer before showing feeding cues, so no feed at 20 minutes is expected. Eye prophylaxis, the physical examination and weighing, and the vitamin K, hepatitis B, and BCG injections are done at the bedside after the first full breastfeed.

## 심화 해설

Core EINC principle

The DOH Essential Intrapartum and Newborn Care protocol is built on a specific sequence: a stable mother and newborn remain in uninterrupted skin-to-skin contact until the first full breastfeed is completed. This is not a passive waiting period; it is the first and most important newborn intervention. Routine procedures that can safely wait—eye prophylaxis, weighing, physical examination, vitamin K, hepatitis B, and BCG—are intentionally delayed until after that first feed.

At 20 minutes after birth, the absence of feeding is an expected finding, not a problem. Healthy term newborns commonly rest for 20 to 30 minutes or longer before showing feeding cues. The baby is in a quiet-alert or sleep phase, and the mother’s chest provides thermoregulation, glucose stability, and colonization with maternal flora. Removing the baby now would interrupt this physiologic transition.

Key point! The first full breastfeed is the milestone that ends the “first embrace” period. Only after it occurs do the other routine newborn procedures begin—and they are done at the bedside, with the baby staying close to the mother.

Why the other options are incorrect

| Option | Problem |
| --- | --- |
| 1. Give vitamin K now while the baby stays on the mother’s chest | Vitamin K is a routine injection, but EINC does not move it ahead of the first breastfeed. Giving it now still violates the sequence, even if the baby remains in place. |
| 2. Weigh the baby quickly and return within 5 minutes | Weighing is a non-urgent procedure. Any separation—even brief—interrupts skin-to-skin contact and delays the first feed. EINC does not allow “quick” interruptions for routine measurements. |
| 3. Give eye ointment now, since the baby is not yet feeding | Eye prophylaxis is important, but it is not time-critical in the first hour for a healthy newborn. The fact that the baby has not fed yet is exactly why the nurse should wait, not act. |

Clinical reasoning for the correct answer

The nurse’s best response is to defer eye ointment, weighing, and vitamin K until after the baby’s first full breastfeed. This preserves the EINC sequence and protects the newborn’s transition. The staff member’s concern about the baby “not yet feeding” reflects a misunderstanding of normal newborn behavior; the nurse should explain that the baby is still in the early resting phase and that feeding cues will appear.

The first full breastfeed is both a nutritional event and a developmental milestone that signals readiness for the next steps of routine care. Once it occurs, the nurse can perform all delayed procedures at the bedside without separating mother and baby.

Watch out! In exam questions about EINC, any answer that involves moving the baby away from the mother before the first full breastfeed—even for a “quick” procedure—is almost always wrong. The only exceptions are true emergencies requiring resuscitation, which is not the case here.

## 임상 시나리오

EINC Newborn Care TimingProtecting the First Embrace
Keep a stable mother and newborn in uninterrupted skin-to-skin contact until the first full breastfeed is completed. No feeding at 20 minutes is expected; healthy term babies often rest for 20–30 minutes or longer before showing feeding cues.

Defer eye prophylaxis, weighing, physical examination, vitamin K, hepatitis B, and BCG until after the first full breastfeed. Perform these at the bedside with the baby staying close to the mother.

CautionDo not interrupt skin-to-skin contact for routine procedures, even if the baby remains on the mother's chest during the intervention. The first full breastfeed is the milestone that ends the first embrace period—not a set time interval.

## 핵심 개념

- **EINC** — Essential Intrapartum and Newborn Care; a DOH protocol prioritizing uninterrupted skin-to-skin contact and early breastfeeding for stable mothers and newborns.
- **Skin-to-skin contact** — Placing the naked newborn prone on the mother's bare chest immediately after birth, maintained until the first full breastfeed for thermoregulation, bonding, and physiologic stability.
- **First full breastfeed** — The milestone marking the end of the initial skin-to-skin period; routine newborn procedures are deferred until after this event.
- **Eye prophylaxis** — Application of antibiotic eye ointment to prevent ophthalmia neonatorum; in EINC, performed after the first full breastfeed at the bedside.
- **Vitamin K administration** — Intramuscular injection given to prevent hemorrhagic disease of the newborn; deferred until after the first full breastfeed under EINC.

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