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
A) Respiratory rate of 72 breaths per minute
B) Negative Babinski reflex
C) Mean blood pressure of 52 mmHg
D) Acrocyanosis
E) Presence of meconium stool
Answer: A, 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.
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