Normal Variations and Abnormal Findings
Normal Variations and Abnormal Findings ( 5 Questions)
A nurse is using the New Ballard Scale to assess the gestational age of a newborn.
Which of the following physical characteristics should the nurse evaluate? (Select all that apply.)
The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals. The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.
The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals. The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.
The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals. The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.
Hair pattern is not one of the physical characteristics used in the New Ballard Scale.
The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals. The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.
The correct answer is choice A, B, C and E. The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics. The physical characteristics include skin texture, lanugo, plantar surface, breast tissue, eye/ear and genitals. The neuromuscular characteristics include posture, square window, arm recoil, popliteal angle, scarf sign and heel to ear.
The nurse should evaluate all these characteristics and assign a score for each one. The total score determines the gestational maturity in weeks.
Choice D is wrong because hair pattern is not one of the physical characteristics used in the New Ballard Scale.
Hair pattern may vary depending on genetic factors and is not a reliable indicator of gestational age.
The normal ranges for each characteristic are given in the table below:
|
Characteristic |
Score |
-1 |
0 |
1 |
2 |
3 |
4 |
5 |
|
Posture |
Extended |
Flexed |
Full flexion |
|||||
|
Square window |
>90° |
90° |
60° |
45° |
||||
|
Arm recoil |
Extended |
Slight flex |