The nurse is observing an infant and notes that the infant is restless, wide-awake but quiet. The mother reports that her baby often is awake for hours at a time and is very fidgety. How would the nurse respond to her observation?

Choice A reason: Prescribing medication to calm an infant is premature without investigating the cause of restlessness and prolonged wakefulness. An in-depth assessment identifies underlying issues like medical or environmental factors, making this reactive and incorrect compared to a thorough evaluation of the infant’s behavior. Choice B reason: Reporting to a supervisor is unnecessary before assessing the infant’s restlessness and wakefulness. Conducting an in-depth investigation allows the nurse to gather data on potential causes, making this less direct and incorrect compared to initiating a thorough assessment of the infant’s condition first. Choice C reason: Restlessness and prolonged wakefulness in an infant warrant an in-depth investigation to identify causes like medical issues, feeding problems, or environmental factors. This aligns with pediatric nursing assessment principles, ensuring a comprehensive approach to the infant’s behavior, making it the correct response for the nurse. Choice D reason: Assuming the behavior is normal because the mother reports it dismisses potential underlying issues causing restlessness. An in-depth investigation is needed to rule out medical or environmental factors, making this incorrect, as it risks overlooking conditions requiring intervention in the infant’s care.