Health Promotion and Maintenance
95. A nurse attempts to give a newborn infant the first bottle feeding. While sucking, the infant becomes cyanotic and coughs, and formula is seen coming out of the infant's nose. What should be the nurse's first action?
. Auscultate the lungs.
. Suction the child's airway.
. Obtain an order for an x-ray.
. Contact the physician.
Test-Taking Tip
It is helpful to remember the 3 C's of TEF: coughing, choking, and cyanosis. A nurse's top priority should be the airway of an infant with these symptoms.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Health Promotion and Maintenance
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Answer 1 is incorrect because, although the nurse should assess the child's lungs for possible aspiration, the first action is to clear the airway. Answer 2 is correct because the nurse's first action should be to clear the child's airway of formula. Since this is the infant's first feeding, the nurse should suspect a tracheoesophageal fistula (TEF) and should not attempt to feed the child again. Answer 3 is incorrect because an x-ray may be obtained after the child's airway is stabilized. Answer 4 is incorrect because the nurse should first stabilize the airway and assess the child before contacting the physician.