At birth, an infant newborn has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?
1. Assess blood pressure.
2. Deep suction the airways.
3. Begin chest compressions.
4. Begin bag-and-mask ventilation.
4
Explanation:
1. Establishment of airway and breathing take priority over assessment of blood pressure.
2. This would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid.
3. Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established.
4. When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure.
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