Physical Assessment Findings Flashcards
Nursing Actions during a Physical Assessment
-Take time to play and develop rapport
-Observe for behaviors that demonstrate the child’s readiness to cooperate
-Explain each step of the exam to the child
Parts of explaining steps of an exam to a child
-use age appropriate language
-demonstrate what will happen with dolls
-allow the child manipulate and handle equipment on others
Temperature
97.8-100.4
Newborn Pulse Rate, BP, Respirations
110-160
64/41
30-60
Infant Pulse Rate, BP, Respirations
90-160
85/50
25-30
Toddler Pulse Rate, BP, Respirations
80-140
91-85/49-37
25-30
Preschooler Pulse Rate, BP, Respirations
70-120
98-89/53-46
20-25
Sucking and Rooting reflex
elicited by stroking an infant’s cheek or the edge of an infant’s mouth
Infant responds by turning their head toward the side that is touched and starts to stuck
Palmar Grasp
Elicited by placing an object in an infant’s palm
The infant grasps the object
Plantar Grasp
Elicited by touching the sole of an infant’s foot
The infant’s toe curl downward
Moro reflex
Elicited by allowing the head and trunk of an infant in a semi-sitting position to fall backward to an angle of at least 30 degrees
The infant’s arms and legs symmetrically extend, then abduct while fingers spread to form C shape
Tonic Neck Reflex
Elicited by turning an infant’s head to one side
The infant extends the arm and leg on that side and flexes the arm and leg on the opposite side
Babinski reflex
Elicited by stroking the outer edge of the sole of an infant’s foot up toward the toes
The infant’s toes fan upward and out
Cranial Nerve I
olfactory: identifies smells
Cranial Nerve II
optic: visual acuity, peripheral vision, and color vision
