The nurse is performing a gestational age assessment on a newborn. Which characteristics indicate a preterm newborn? (Select all that apply.)
a. Translucent skin
b. Extended limp arms and legs
c. The ear springs back when folded
d. Square window angle of 45 degrees or less
e. Large clitoris and labia minora in the female newborn
ANS: A, B, E
The very preterm infant's skin is translucent because it is thin and has little subcutaneous fat beneath the surface. Preterm neonates have immature flexor muscles and little energy or muscle tone. Therefore they have extended and limp arms and legs that offer little resistance to movement by the examiner. In the preterm female infant, the labia majora are small and separated, and the clitoris and labia minora are large by comparison. In the term neonate, the ear springs back to its original position immediately. The more mature the neonate, the smaller the angle of the square window assessment until the palm folds flat against the forearm at term, the result of maternal hormones at the end of pregnancy.
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