The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take?
1. Immediately contact the infant's physician.
2. Prepare to resuscitate the infant.
3. Note this normal finding in the infant's medical record.
4. Stimulate the infant gently.
Correct Answer: 3
Rationale 1: There is no need to contact the infant's physician.
Rationale 2: This infant does not need resuscitation.
Rationale 3: An irregular heart rate of 140 is common and normal in an infant of this age. The finding should be recorded in the medical record.
Rationale 4: This infant does not need stimulation.
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