A nursing instructor is demonstrating an assessment on a newborn using the Ballard gestational assessment tool
The nurse explains that which of the following tests should be performed after the first hour of birth, when the newborn has had time to recover from the stress of birth? 1. Arm recoil
2. Square window sign
3. Scarf sign
4. Popliteal angle
1
Rationale 1: Recoil time is slower in fatigued newborns. Therefore, arm recoil is best elicited after the first hour of birth so the newborn has time to recover from the stress of birth.
Rationale 2: The square window sign does not have to be assessed after the first hour of birth.
Rationale 3: The scarf sign does not have to be assessed after the first hour of birth.
Rationale 4: The popliteal angle does not have to be assessed after the first hour of birth.
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