A nurse in the neonatal intensive care unit discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action?

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11ecbb05_caa9_8352_b433_c9cfc611845a_MD0009_00 The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx) to clear the airway (Option D). Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia (EA) and tracheoesophageal fistula (TEF). If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair. (Option A) Oxygen cannot be delivered to the lungs if secretions obstruct the airway. Therefore, suctioning is a priority. (Option B) This infant is aspirating and in immediate distress, which should be addressed without delay. After suctioning the excess saliva and ensuring a clear airway, the nurse may perform further assessments. (Option C) This infant's cyanosis is a result of aspirating secretions and does not indicate a circulatory problem. The knee-chest position is appropriate to increase pulmonary blood flow in infants with a cyanotic heart defect (eg, tetralogy of Fallot). Educational objective: The initial nursing action for a client experiencing cyanosis and excess oral secretions is oropharyngeal suctioning to ensure airway patency.

A Nurse in the Neonatal Intensive Care Unit Discovers a Cyanotic