Before the nurse begins to dry the newborn off after birth, which of the following assessment findings should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool?
1. Amount and area of vernix coverage
2. Creases on the sole
3. Size of the areola
4. Body surface temperature
1
Rationale:
1. Drying the baby after birth will disturb the vernix and potentially alter the score when using the Ballard gestational assessment tool. The nurse first should document the amount and coverage of the vernix before drying the newborn.
2. Creases on the sole are not affected by drying of the newborn.
3. Size of the areola is not affected by drying of the newborn.
4. Body surface temperature is not part of the Ballard gestational assessment tool.
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