In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. what is the most appropriate nursing action in response to this behavior?
1. documenting an intact reflex.2. assessing the infant's vital signs.3. testing the infant's ability to hear.4. stimulating the infant's respirations.

The correct answer would be option A.

Explanation:

The primary response in this case by nurse should be observing the reflection of the startle reflexes that is is the brainstem reflectory reaction, that shows the rapid and random moments, when there is repetitive stimulus present.

So, the correct response would be documenting the intact reflexes. Habituation is known as the lowering in response, it is not necessary as it is noisy room and infants response is on the noise.

Thus, the correct answer is - option A.

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