A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? A. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex Answer: Substernal chest retractions while sleeping A. Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. B. Murmur at the left sternal border An audible murmur heard at the left sternal border is an expected manifestation in newborns. C. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. D. Positive Babinski reflex A positive Babinski reflex is an expected manifestation in newborns. This reflex is elicited when a newborn's sole is stroked with a finger upward along the lateral aspect of the sole and then across the ball of the foot and, in response, the t FHR can be heard by a doppler at 10-12 weeks gestation when should a nurse start measuring a woman's fundal height? after 12 weeks gestation between 18-30 weeks