Section: NCLEX

41) Which of the following observations of a 8 lb 4 oz newborn boy, if made by the nurse, would require an intervention?

1. The infant’s respirations are 36, shallow and irregular in rate, rhythm, and depth.
2. The infant’s axillary temperature is 96.2° F (35.6° C).
3. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line.
4. There is asynchronous spontaneous movement of the infant’s extremities.

This subnormal temperature indicates prematurity, infection, low environment temperature, inadequate clothing, and/or dehydration