# Situation: A 30-year-old woman at 39 weeks' gestation, who has had two previous term vaginal births, is in active labor at a district hospital. She attended psychoprophylaxis childbirth classes during pregnancy and prefers to avoid drug analgesia. Her husband stays with her. The client gives birth vaginally through clear amniotic fluid. The baby is placed on the mother's abdomen and dried thoroughly. At 30 seconds, the baby takes an occasional deep gasp every few seconds, has poor muscle tone, and has not cried. The mouth and nose are free of secretions, and the cord is still pulsating. According to the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol, what should the nurse do next?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629481  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 30-year-old woman at 39 weeks' gestation, who has had two previous term vaginal births, is in active labor at a district hospital. She attended psychoprophylaxis childbirth classes during pregnancy and prefers to avoid drug analgesia. Her husband stays with her.

The client gives birth vaginally through clear amniotic fluid. The baby is placed on the mother's abdomen and dried thoroughly. At 30 seconds, the baby takes an occasional deep gasp every few seconds, has poor muscle tone, and has not cried. The mouth and nose are free of secretions, and the cord is still pulsating. According to the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol, what should the nurse do next?

## 보기

1. Suction the mouth and then the nose before any other step
2. Keep the baby skin-to-skin and clamp the cord once pulsations stop
3. Assign a 1-minute Apgar score, then decide whether to resuscitate
4. Clamp and cut the cord, call for help, and begin resuscitation **✔ 정답**

**정답: 4**

## 해설

Under EINC, a baby who is breathing or crying after about 30 seconds of drying stays skin-to-skin, and the cord is clamped after pulsations stop. Gasping is not effective breathing: a baby who is not breathing or is gasping after 30 seconds has the cord clamped and cut, help is called, and basic resuscitation with ventilation begins. Suction is not needed when the mouth and nose are clear, and further stimulation only delays ventilation.

## 심화 해설

Gasping is not breathing
Under the Department of Health (DOH) Essential Intrapartum and Newborn Care (EINC) protocol, every newborn is dried thoroughly for about 30 seconds and then reassessed. A baby who is breathing or crying stays skin-to-skin, and the cord is clamped after pulsations stop. This baby has only occasional deep gasps, poor muscle tone, and no cry. Gasping is not effective breathing, so a gasping baby after 30 seconds of drying is managed as a non-breathing baby: clamp and cut the cord, call for help, and begin resuscitation.

Why the cord is clamped now
For a breathing baby, delaying cord clamping is beneficial. For a baby who needs ventilation, the priority is to move the baby to a warm, firm surface where bag-and-mask ventilation can be done effectively. The cord is therefore clamped and cut immediately, and the baby is transferred to the resuscitation area. The goal is to begin ventilation within the first minute of life, sometimes called the golden minute, because every delay worsens hypoxia.

Why suction is not the next step
The mouth and nose are free of secretions and the amniotic fluid is clear. Routine suction is not done in EINC; it is used only when secretions block the airway. Suctioning a baby with a clear airway delays ventilation and can cause bradycardia through vagal stimulation. Further rubbing or stimulation beyond drying also only delays what the baby needs. Watch out! The option to suction the mouth and then the nose describes the correct order of suction, but suction itself is not indicated here.

Why the Apgar score is not used to decide
The Apgar score is assigned at 1 and 5 minutes to describe the baby's condition, but it is not used to decide whether to start resuscitation. Waiting for the 1-minute score would mean losing the most critical seconds. Decisions in the first minute are based on whether the baby is breathing or crying after drying, not on a score.

| Finding after 30 seconds of drying | EINC action |
| --- | --- |
| Breathing or crying | Keep skin-to-skin; clamp the cord after pulsations stop |
| Not breathing or gasping | Clamp and cut the cord, call for help, begin resuscitation with ventilation |
| Secretions blocking the airway | Suction the mouth, then the nose, only as needed |

Exam takeaway
In EINC, a baby who is not breathing or is gasping after drying needs immediate cord clamping, a call for help, and ventilation; it does not wait for suction or the Apgar score. Key point! Gasping, poor tone, and no cry together signal that the baby needs help now.

## 임상 시나리오

Gasping Newborn at 30 SecondsEINC response for a baby who is not breathing well
After about 30 seconds of drying, reassess: a baby who is breathing or crying stays skin-to-skin with delayed cord clamping.

A baby who is not breathing or gasping has the cord clamped and cut, help is called, and resuscitation with ventilation begins within the first minute.

Suction only when secretions block the airway; here the mouth and nose are clear.

CautionDo not wait for the 1-minute Apgar score, and do not delay ventilation with routine suction or extra stimulation.

## 핵심 개념

- **Gasping** — Irregular, deep, ineffective breaths that signal severe hypoxia; it is treated as not breathing.
- **EINC** — Essential Intrapartum and Newborn Care, the DOH time-bound protocol for care during and after birth.
- **Apgar score** — A 0-to-10 rating of the newborn's condition at 1 and 5 minutes; it does not guide the start of resuscitation.
- **Bag-and-mask ventilation** — Delivering breaths to a newborn with a self-inflating bag and a face mask during resuscitation.
- **Golden minute** — The first minute after birth, within which ventilation should start for a baby who is not breathing.

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