If a child is not breathing, the first nursing action should be?

RUHS, Jaipur, PB B.Sc Nursing Entrance-2021

Child Health Nursing (Pediatrics)

Easy

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2021

Explanation

The correct action follows the ABCs of resuscitation: Airway, Breathing, Circulation.
Clearing the airway is the first priority because without a patent airway, subsequent steps like providing breaths or oxygen will be ineffective.
In children, respiratory arrest is a more common cause of cardiopulmonary arrest than primary cardiac events, making airway management the most critical initial step.
Maneuvers to open the airway include the head-tilt, chin-lift or jaw-thrust, and removing any visible obstructions.

Option A: This is the 'Breathing' step in the ABC sequence. It should only be performed after ensuring the airway is open and clear.
Option C: Providing oxygen is a part of supporting 'Breathing'. It is futile if the airway is obstructed, as the oxygen will not reach the lungs.
Option D: This is the 'Circulation' step in the ABC sequence. It is indicated for cardiac arrest (no pulse or heart rate less than 60/min with signs of poor perfusion), not for isolated respiratory arrest where a pulse is still present.

Clinical Relevance

Nursing practice connection: Use the key finding related to Priority nursing action in pediatric basic life support (BLS) to guide bedside assessment, documentation, and the next nursing action.
In any resuscitation scenario, always remember the ABCs (Airway, Breathing, Circulation) to prioritize interventions correctly. Airway always comes first.
A nurse must be able to quickly assess for signs of airway obstruction (e.g., no breath sounds, paradoxical chest movement, cyanosis) and act immediately.
What if? If the child was found after a fall from a height and is not breathing, the first action is still to open the airway, but you MUST use the jaw-thrust maneuver instead of the head-tilt, chin-lift to protect the cervical spine from potential injury.

How to Approach the Question

Identify the keywords in the question: 'child', 'not breathing', and 'first nursing action'.
Recognize that this is a priority-setting question in an emergency situation.
Recall the fundamental principles of Basic Life Support (BLS), specifically the ABC sequence: Airway, Breathing, Circulation.
Apply the ABC sequence to the options. 'Clear the airway' corresponds to 'A' (Airway).
Evaluate the other options in the context of the ABCs. 'Mouth-to-mouth' and 'O2 therapy' relate to 'B' (Breathing), and 'chest compression' relates to 'C' (Circulation).
Conclude that the 'Airway' step must be performed before the 'Breathing' and 'Circulation' steps, making 'Clear the airway' the correct first action.

Concept Tested & Keywords

Concept Tested: Priority nursing action in pediatric basic life support (BLS).
Stem keywords: child, not breathing, first nursing action
Lead-in keywords: first
Clinical cues: Age/sex group narrows the expected diagnosis, intervention, or normal reference range.
Negative lead-in flag: false

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E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 763-765

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 599-601