Select all that apply.

A nurse is providing comfort measures to a newborn during an assessment.

What non-pharmacological interventions can the nurse use to soothe the newborn?

It helps identify potential developmental delays.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.The scale can be used when there is no reliable obstetrical information or a major discrepancy between the estimated date of delivery and the infant’s appearance.The scale is accurate only within plus or minus 2 weeks and can be used up to 4 days after birth, but usually within the first 24 hours.The scale has been refined and expanded to include extremely premature neonates.

Choice A is wrong because the New Ballard Scale does not determine the newborn’s nutritional needs.It only assesses the gestational maturity of the newborn based on physical and neuromuscular signs.

Choice B is wrong because the New Ballard Scale does not assess the baby’s cognitive development.It only estimates the gestational age of the newborn, which is the primary determinant of organ maturity.

Choice D is wrong because the New Ballard Scale does not measure the newborn’s respiratory function.It only evaluates the physical and neuromuscular characteristics of the newborn, such as skin texture, lanugo, plantar surface, breast tissue, eye/ear development and genitalia.

Darkening of the mucosa.This is an expected variation for an older adult client because the melanin production increases with age.

Some possible explanations for the other choices are:

• Choice A.White patches on the tongue could indicate candidiasis, an oral fungal infection.

• Choice B.Bleeding of the gums could indicate gingivitis, periodontitis, or vitamin C deficiency.

• Choice C.Red spots on the hard palate could indicate petechiae, which are small hemorrhages caused by trauma, infection, or bleeding disorders.

Normal ranges for oral mucosa color vary depending on the skin tone and ethnicity of the client.Generally, the oral mucosa should be pink and moist without lesions or discolorations.