Assessment findings of a 4-hour-old newborn include an 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, hypotonia, and a weak cry. Based on these findings, which action should the nurse implement?

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