A nurse observes an infant in a crib lying still, without facial movements, except for occasional sucking movements. At this time, the nurse will avoid:
1. Assessing heart and respiratory rate.
2. Skin assessment.
3. Repositioning the head of the infant.
4. Attempts to feed the infant.
4
Rationale:
1. There is no contraindication to assessing the heart and respiratory rate.
2. There is no contraindication to assessing the infant's skin.
3. Repositioning the head of the infant is acceptable to do while the infant is in a deep sleep.
4. This infant is in a quiet, deep sleep. Attempts to feed the infant should not be made until the infant is in a lighter sleeping pattern, since the infant will be unresponsive to attempts at arousal, and might be at risk for aspiration.
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