The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply.

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A)Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.
B)Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.
C)Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.
D)Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.
E)Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.

The Nurse Is Proving Care to a 1-Hour-Old Newborn Who