A nurse assesses an infant with a heart rate of 50, cyanotic, and apneic. The nurse should initially
A nurse assesses an infant with a heart rate of 50, cyanotic, and apneic. The nurse should initially
A. start chest compressions.
[22%]
B. notify the code/rapid response team.
[54%]
C. deliver rescue breaths.
[20%]
D. obtain intravenous access.
[5%]
Statistics
Subject/Lesson
Subject
Critical Care
Lesson
Critical Care Concepts
Client Need
Test Plan
Physiological Adaptation
Related Topic
Medical Emergencies
Item Type
Item Type
Application
Explanation
Choice B is correct. According to the Basic Life Support (BLS) algorithm, for an infant with a heart rate below 60, showing signs of poor perfusion and apnea, the initial action would be to call a code blue (infant). Once this is completed, the nurse should start CPR at a rate of thirty compressions to two rescue breaths (one rescuer). If two rescuers are involved, child CPR should be administered at a rate of 15 compressions per two breaths.
Choices A, C, and D are incorrect. Chest compressions will need to be initiated following the signaling of a code blue. An infant's heart rate below 60 is grossly inadequate to sustain perfusion. Two rescue breaths must be delivered after thirty chest compressions (one rescuer). Peripheral intravenous access will need to be obtained, but this is not the priority for an infant experiencing cardiac arrest.
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2 Key Topics
CPR
8.2 Risk Management & Environment Safety
Additional Info
For an infant requiring basic life support, it is essential to keep the following points in mind –
✓ Chest compressions may be delivered using the two-finger or two-thumb encircling hands technique.
✓ The chest should be depressed 1.5 inches and allowed to recoil.
✓ The chest compression rate should be approximately 100 to 120 per minute.
✓ For a single rescuer, the nurse should perform compressions at 30 (compressions) to 2 (rescue breaths).
✓ For two rescuers, the ratio of compressions to rescue breaths changes to 15 (compressions) to 2 (rescue breaths).
✓ An AED should be obtained as soon as possible to increase the odds of survival from ventricular dysrhythmias.
✓ The airway should be opened with the head tilt-chin lift maneuver unless a cervical spinal cord injury is suspected; if it is suspected, utilize the jaw thrust maneuver.
✓ If a pulse is present and rescue breaths are required, one breath should be given via a bag valve mask at a rate of one breath every two to three seconds.
