The nurse is performing an assessment on a 4-hour old newborn. Findings include temperature 36.2° C (97.2° F), heart rate 162 beats/minute, respiratory rate 62 breaths/minute with 20-second pauses. The nurse's first action should be to:
a. Notify the health care provider.
b. Recheck vital signs in 1 hour.
c. Document findings as normal.
d. Return the newborn to the mother's room for rooming-in.
ANS: A
Although all vital signs are barely abnormal (normal: temperature 36.5° C [97.7° F], heart rate 110-160 beats/minute, respiratory rate 30-60 breaths/minute with 5- to 15-second pauses), the health care provider should be notified because these may be early signs of cold stress or other abnormality. The infant should be warmed before rechecking vital signs. The infant may be returned to its mother for rooming-in but only after health care provider has been notified.
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