Prioritizing Actions in Infant Resuscitation: A Step-By-Step Guide for Nurses

The nurse enters the client’s room and realizes the 9-month-old infant is not breath- ing. Which interventions should the nurse implement? Prioritize the nurse’s actions from first (1) to last (5).1. Perform cardiac compression 30:2.2. Check the infant’s brachial pulse. 3. Administer two puffs to the infant. 4. Determine unresponsiveness.5. Open the infant’s airway.

When faced with an unresponsive 9-month-old infant who is not breathing, the nurse needs to take immediate action to initiate resuscitation

When faced with an unresponsive 9-month-old infant who is not breathing, the nurse needs to take immediate action to initiate resuscitation. The nurse should prioritize the following actions from first (1) to last (5):

1. Determine unresponsiveness:
The first step is to assess whether the infant is unresponsive. The nurse should gently tap the infant’s foot or shoulder and call out for a response. If there is no response, the nurse can assume the infant is unresponsive and move on to the next step.

2. Open the infant’s airway:
To maintain a patent airway, the nurse should position the infant on their back and gently tilt their head back, using hand placement on the forehead and chin. This helps to lift the tongue off the back of the throat, allowing for better airflow.

3. Check the infant’s brachial pulse:
After ensuring the airway is open, the nurse should immediately check for the presence of a brachial pulse. This is done by palpating the inner side of the upper arm just above the elbow crease. The absence of a pulse indicates the need for immediate intervention.

4. Perform cardiac compression 30:2:
If the nurse does not detect a brachial pulse, they should begin cardiopulmonary resuscitation (CPR) immediately. CPR for infants involves a compression-to-ventilation ratio of 30:2. The nurse should position the infant on a hard surface, place two fingers in the center of the infant’s chest (just below the nipple line), and deliver compressions at a rate of approximately 100-120 compressions per minute. After 30 compressions, the nurse should provide two breaths using a bag-mask device or mouth-to-mouth technique.

5. Administer two puffs to the infant:
Administering two puffs to the infant refers to providing rescue breaths using a bag-mask device with supplemental oxygen. This step should be implemented once the nurse has performed the initial 30 compressions. By providing oxygen-rich breaths, the nurse can help increase the oxygenation of the infant’s blood.

It is important to note that if there is another healthcare provider present, they can assist with the interventions, including providing compressions while the nurse opens the infant’s airway and checks for a pulse. Additionally, the nurse should activate the emergency response system or call for assistance as soon as possible.

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