The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first?

• A. Provide tactile stimulation.
• B. Administer flow by 100% oxygen.
• C. Assess the functionality of the monitoring device.
• D. Evaluate the newborn's color and respirations.

Answer: (D)

When an apnea monitor alarm sounds, the first action is to assess the newborn’s actual status by checking color and respirations. This quick bedside assessment tells you whether the infant is in distress and needs immediate intervention, or if the alarm may be due to a nonclinical issue such as electrode placement or a sensor problem. If the infant is cyanotic or has irregular or absent respirations, you would proceed with appropriate interventions right away. If the infant looks pink with normal respirations, the alarm is more likely related to equipment, and you would then verify monitor function and electrode placement.

Tactile stimulation might be used if there is a brief pause in breathing and the infant needs help resuming respiration, but you wouldn’t start there before confirming the infant’s actual status. Checking the device is important after assessing the infant, and giving 100% oxygen is reserved for clear signs of hypoxemia rather than as a first move without assessment.