A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?
1. Begin chest compressions.
2. Deep-suction the airways.
3. Begin bag-and-mask ventilation.
4. Obtain a blood pressure reading.
3
Rationale 1: Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established.
Rationale 2: This would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid in the question.
Rationale 3: When an infant is not breathing and has poor muscle tone, bag-and-mask ventilation is the appropriate resuscitation measure.
Rationale 4: Blood pressure is insignificant during resuscitation efforts. This infant needs respirations established.
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