The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant's gestational age is 33 weeks based on early ultrasound and last menstrual period. The nurse expects the infant to exhibit:
1. Full sole creases, nails extending beyond the fingertips, scarf sign showing the elbow beyond the midline
2. Testes located deep in the scrotum, rugae covering the scrotum, vernix covering the entire body
3. Ear cartilage folded over, lanugo present over much of the body, some flexion of arms and legs at rest
4. 1 cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension
3
Rationale 1: Full sole creases and nails beyond the fingertips are seen in term infants; a scarf sign beyond the midline is characteristic of a preterm infant.
Rationale 2: Deep testes and rugae-covered scrotum are seen in term infants. Vernix covering the body is an indication of a preterm infant.
Rationale 3: All these characteristics are characteristic of a preterm infant.
Rationale 4: One cm breast bud, peeling skin, the presence of adipose tissue so that veins are not visible, and rapid recoil of the legs and arms are all indications of term-to-post–term infants.
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