Health Promotion and Maintenance
23. A 1-day-old infant, born at 39 weeks' gestation, weighs 4 pounds, 7 ounces at birth. A pediatrician diagnoses the neonate with intrauterine growth restriction (IGR). An RN observes the newborn to be irritable, difficult to console, restless, fist-sucking, and demonstrating a high-pitched, shrill cry. Based on these assessment data, the RN should:
. Increase stimulation of the baby by handling the infant as much as possible.
. Schedule routine feeding times every 3 to 4 hours.
. Encourage stimulation by rubbing the infant's back and head.
. Tightly swaddle the infant in a flexed position.
Test-Taking Tip
The focus is on decreasing the irritability in the infant. Choose the interventions that will decrease stimulation and enhance security for the infant.
Content Area: Child Health, Newborn; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because this infant needs comfort and security with decreased stimulation. Increasing stimulation will not meet this infant's needs. Answer 2 is incorrect because this infant will benefit from small, frequent feedings on demand rather than a schedule that may increase stimulation by arousing the infant to eat on a defined schedule. Answer 3 is incorrect because this infant needs comfort and security with decreased stimulation. Increasing stimulation by rubbing will increase the infant's irritability. Answer 4 is correct because tightly swaddling the baby promotes the infant's comfort and security and decreases the stimulation that may contribute to the infant's irritability.