Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?

A Document the findings in the record D Swaddle the infant in a warm blanket C Place a pulse oximeter on the heel. B Obtain a heel stick blood glucose level.