Before the nurse begins to dry off the newborn after birth, which assessment finding 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 should document the amount and coverage of the vernix before drying the newborn.
Rationale 2: Creases on the sole are not affected by drying the newborn.
Rationale 3: The size of the areola is not affected by drying the newborn.
Rationale 4: Body surface temperature is not part of the Ballard gestational assessment tool.
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