The nursing instructor is demonstrating a newborn assessment using the Ballard gestational assessment tool. Which assessment should be performed after the first hour of birth?

Question

1. Scarf sign
2. Arm recoil
3. Popliteal angle
4. Square window sign

Answer 1

2
Explanation:
1. The scarf sign is elicited by placing the newborn supine and drawing an arm across the chest toward the newborn's opposite shoulder until resistance is met. A preterm infant's elbow will cross the midline of the chest, whereas a full-term infant's elbow will not cross midline.
2. 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.
3. The popliteal angle (degree of knee flexion) is determined with the newborn flat on the back. The thigh is flexed on the abdomen and chest, and the nurse places the index finger of the other hand behind the newborn's ankle to extend the lower leg until resistance is met. The angle formed is then measured. Results vary from no resistance in the very immature newborn to an 80-degree angle in the term newborn.
4. The square window sign is elicited by gently flexing the newborn's hand toward the ventral forearm until resistance is felt. The angle formed at the wrist is measured.