248 Chapter 2 Physical Assessment Findings

what is a nursing action related to room lighting?

keep room warm and well lit

what nursing action relates to medical equipment and environment of examinations

keep it out of sight and perform under nonthreatening environments

how would you explain each step of an examination?

demonstrate using dolls, puppets, or paper drawings + allow child to manipulate equipment as well as use it on others

expected temperature of birth through 4 weeks in CELSIUS

36.5-37.5C

expected temperature of birth through 4 weeks in FAHRENHEIT

97.7-99.5F

expected temp for 1 month through 12 years CELSIUS

36.4-37.5C

expected temp for 1 month through 12 years FAHRENHEIT

97.5-99.5F

expected temp for 13 years through 18 years CELSIUS

36.4-37.5C

exp temp for 13-18 FHR

97.5-99.5F

what route is utilized through 5years of age if exact measurement is necessary

rectal

what year of age can tympanic route be utilized

beginning at 3 years of age

what route can be utilized if child is cooperative at 4 years of age

oral

norm pulse for newborn

110-160/min

norm pulse for infant 1-12 mo

90-160/min

norm pulse for toddler 1-2 yo

80-140/min

norm pulse for preschooler 3-5 yo

70-120/mins

norm pulse for school age 6-12 yo

60-110/min

norm pulse for adolescent 13-18 yo

50-100/min

norm respiration for newborn (birth to 4wks)

30-60/min

norm rr for infant

25-60

norm rr for toddler

25-30

norm rr for perschooler

20-25

norm rr for schoola ge

20-25

norm rr for adolescent

16-20

avg bp for newborn

64/41

avg bp for infant

85/50

avg max bp for male toddler

91/46

avg max bp for female toddler

89/49

avg min bp for male toddler

85/37

avg min bp for female toddler

86/40

avg max bp for male preschooler

98/53

avg max bp for female preschooler

93/54

avg min bp for male preschooler

91/46

avg min bp for female preschooler

89/49

avg max bp for male school age

106/62

avg max bp for female school age

106/62

avg min bp for male school age

96/55

avg min bp for female school age

94/56

skin condition common for newborn within the first month

acrocyanosis

fontanels should be

soft and flat

the posterior fontanel usually closes by

8 weeks of age

the anterior fontanel usually closes between

12-24 months of age

infants are expected to hold their head steady without support by

4 months

infants may have 6-8 teeth by

1 year of age

children will have approximately 20 teeth by

3 years

irises should be round with the permanent color manifesting around

6-12 months of age

what tests check visual acuity of children unable to read letters or numbers

LEA symbols or HOTV test

what tests assess far vision and color in preschool and school aged children?

Snellen eye chart and Ishihara plates

Finger to nose test

rapid coordinated movementsH

Heel to shin test

able to run the heel of one foot down the shin of the other leg while standing

what do the finger to nose and the heel to shin test?

cerebellar function

what is expected in infants after 4 months of age

erect head posture

extraocular movements might not be symmetric in

newborns

irregular respiratory rates are expected in

infants

respirations should be regular and symmetrical in children

12 months and older without use of accessory muscles

newborns may initially have a murmur noted during auscultation as teh

ductus arteriosius closes

adventitious sounds such as clicks, murmurs, rubs, and extra sounds are considered

unexpected after first few days after birth and warrant followup

normoactive peristaltic sounds should be heard upon ausculatation and what are considered unexpected?

hyperactive, hypoactive, and vascular

sucking and rooting reflexes develop when

birth to 4 months

palmar grasp

develops from birth to 4 months

plantar grasp develops

from birth to 8 months

moro reflex

develops from birth to 4 months

what is a 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°
The infant’s arms and legs symmetrically extend, then
abduct while fingers spread to form C shape.

Tonic Neck Reflex (Fencer Position)

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.

tonic neck reflex

Birth to 3 to 4 months

when is babkinski reflex expected

birth to 1 year

when is stepping expected

birth to 4 weeks