The nurse is using the New Ballard Score to assess the gestational age of a newborn delivered 4 hours ago. The infant is 33 weeks by early ultrasound and last menstrual period. The nurse expects the infant to exhibit:
1. Full sole creases, nails extending beyond the fingertips, scarf sign shows the elbow beyond the midline.
2. Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body.
3. Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest,
4. 1cm breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension.
3
Rationale:
1. Full sole creases and nails beyond the fingertips will be seen in term infants; scarf sign beyond the midline is an indication of a preterm infant.
2. Deep testes and rugae-covered scrotum are seen in term infants; vernix covering the body is an indication of a preterm infant.
3. All of these characteristics are indications of a preterm infant.
4. 1cm breast bud, peeling skin, the presence of adipose so that veins are not visible, and rapid recoil of the legs and arms are all indications of term–to–post-term infants.
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