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. Attempts to feed the infant.
3. Skin assessment.
4. Repositioning the head of the infant.
2
Rationale 1: There is no contraindication to assessing the heart and respiratory rate.
Rationale 2: 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 because the infant will be unresponsive to attempts at arousal and might be at risk for aspiration.
Rationale 3: There is no contraindication to assessing the infant's skin.
Rationale 4: Repositioning the head of the infant is acceptable to do while the infant is in a deep sleep.
Global Rationale:
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