A nurse is caring for a newborn who is 4 hours old. The newborn is lying in the bassinet, lightly swaddled.

The newborn appears jittery with a weak cry when disturbed. The extremities are mottled with acrocyanosis.

The respirations are rapid and unlabored. What action should the nurse take?

Choice A rationale
The newborn’s symptoms, such as being jittery with a weak cry when disturbed, mottled extremities with acrocyanosis, and rapid, unlabored respirations, are signs of neonatal abstinence syndrome. This condition can occur in newborns exposed to certain drugs while in the mother’s womb. The first step in managing this condition is to monitor the newborn’s vital
 

signs. This will help the healthcare team assess the newborn’s condition and determine the appropriate treatment plan. Monitoring vital signs is a crucial part of nursing care, especially for newborns who are showing signs of distress. It provides valuable information about the newborn’s physiological status and response to the environment. Regular monitoring can help detect any changes in the newborn’s condition early, allowing for timely intervention.
Choice B rationale
Swaddling the newborn more tightly is not the best action to take in this situation. While swaddling can provide comfort and help soothe a fussy baby, it is not a treatment for the symptoms the newborn is exhibiting. Furthermore, swaddling should be done correctly to avoid any potential risks such as overheating or hip dysplasia. In this case, the newborn’s symptoms need to be addressed directly, which is why monitoring vital signs is a more appropriate action.
Choice C rationale
Administering oxygen to the newborn is not the most appropriate action based on the symptoms described. While the newborn’s respirations are rapid, they are also unlabored, which suggests that the newborn is not currently experiencing respiratory distress. Oxygen therapy is typically reserved for situations where the newborn is showing signs of respiratory distress, such as grunting, flaring nostrils, or cyanosis around the mouth and tongue. In this case, the acrocyanosis (bluish color of hands and feet) is a common and normal finding in newborns due to immature circulation and is not an indication for oxygen therapy.
Choice D rationale
Notifying the healthcare provider is an important step when caring for a newborn showing signs of distress. However, in this situation, the first action the nurse should take is to monitor
 

the newborn’s vital signs. This will provide valuable information about the newborn’s current condition that can be reported to the healthcare provider. It’s important for the nurse to gather as much information as possible before contacting the healthcare provider so that they can have a productive discussion about the newborn’s condition and the next steps in their care.