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.

Question

Quizplus · Accepted Answer

A) Assessment data that would cause this nurse concern include a respiratory rate of 72 breathes per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60-70 breaths per minute. A positive Babinksi reflex is an expected finding. A negative Babinski could indicate neurological compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 50-55 mmHg), acrocyanosis, and passing meconium stool.
B) Assessment data that would cause this nurse concern include a respiratory rate of 72 breathes per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60-70 breaths per minute. A positive Babinksi reflex is an expected finding. A negative Babinski could indicate neurological compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 50-55 mmHg), acrocyanosis, and passing meconium stool.
C) Assessment data that would cause this nurse concern include a respiratory rate of 72 breathes per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60-70 breaths per minute. A positive Babinksi reflex is an expected finding. A negative Babinski could indicate neurological compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 50-55 mmHg), acrocyanosis, and passing meconium stool.
D) Assessment data that would cause this nurse concern include a respiratory rate of 72 breathes per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60-70 breaths per minute. A positive Babinksi reflex is an expected finding. A negative Babinski could indicate neurological compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 50-55 mmHg), acrocyanosis, and passing meconium stool.
E) Assessment data that would cause this nurse concern include a respiratory rate of 72 breathes per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60-70 breaths per minute. A positive Babinksi reflex is an expected finding. A negative Babinski could indicate neurological compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 50-55 mmHg), acrocyanosis, and passing meconium stool.

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