During the routine care condition there was a statistically significant difference between the undisturbed ABSS and the ABSS assessed at 10 minutes. Although infants received four-handed care there were differences noted between the undisturbed ABSS and the ABSS at 2-, 4-, 8-, and 10-minute observations. This finding is consistent with the other research finding (Granau et al.,1998; Stevens et al., 1996) where preterm infants demonstrated sleep and activity changes over the course of noxious procedures. Other researchers suggested that nonphamacologic interventions like four-handed care can also activate the attention of neonates, distracting them and thus modulating their pain response (Bellieni et al., 2001). This finding may explain why in this study when infants received the four-handed care intervention they were in a higher level of attention or alertness. Caution however must be exercised because of the small sample size. This activation of alertness could also substantiate why when infants received four-handed care demonstrated less stress and defense behaviors and demonstrated more self-regulatory and approach behaviors. However, there were no differences in monitor call-backs between conditions, a finding that may also have been affected by the routine use of supportive nesting.