The nurse is bottle feeding a 2-month-old infant. While burping her, the infant vomits formula through her mouth and nose, and begins to choke. The nurse's priority action is to:
1. Suction out the infant's nose.
2. Suction out the infant's mouth.
3. Turn the infant head-down and provide three firm back blows.
4. Call the cardiac resuscitation team.
1
Rationale: Infants until age 6 months are obligate nose breathers, meaning they breathe only through their noses, so the nurse should first clean out the nose and then the mouth, allowing the infant to breathe. Placing the infant head-down would cause her to vomit more, because the cardiac sphincter is not fully formed. A code would not be called unless clearing the airway was unsuccessful.
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