A nursing instructor is demonstrating an assessment on a newborn for the nursing students using the Ballard gestational assessment tool. The nurse explains that which of the following tests should be performed after the first hour 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 can recover from the stress of birth.
2. Square window sign is an assessment performed by the examiner, whereas arm recoil is a response by the newborn.
3. Scarf sign is an assessment performed by the examiner, whereas arm recoil is a response by the newborn.
4. Popliteal angle is an assessment performed by the examiner, whereas arm recoil is a response by the newborn.
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