A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is...

A newborn who is 20 hours old has a respiratory rate of 66, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. Based on these data, the nurse should include which of the following in the management of the infant's care?

1. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours.

2. Place a pulse oximeter and contact the primary health care provider for a prescription to draw blood cultures.

3. Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis.

4. Draw a complete blood count (CBC) with differential and feed the infant.