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ATI Chapter 2
Physical Assessment Findings
46
Nursing
Undergraduate 3
06/06/2013

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Cards

Term
Temp: Birth to 1 year
Definition
36.5-37.2C (97.7 - 98.9F)
Term
Temp: 1 to 12 years
Definition
36.7-37.7C (98.1-99.9F)
Term
Temp: 12+ years
Definition
36.6-36.7C (97.8-98.0F)
Term
Pulse: Birth to 1 week
Definition
100-160/min
Term
Pulse: 1 week - 3 months
Definition
100-220/min
Term
Pulse: 3 months to 2 years
Definition
80-150/min
Term
Pulse: 2 to 12 years
Definition
70-110/min
Term
Pulse: 12+ years
Definition
50-90/min
Term
Resp: Newborn
Definition
30-60/min
Term
Resp: Newborn to 1 year
Definition
30/min
Term
Resp: 1 to 2 years
Definition
25-30/min
Term
Resp: 2 to 6 years
Definition
21-24/min
Term
Resp: 6 to 12 years
Definition
19-21/min
Term
Resp: 12+ years
Definition
16-18/min
Term
BP Infants
Definition
60-80/40-50
Term
BP 1 year
Definition
Girls: 97-107/53-60
Boys: 94-106/50-59
Term
BP 3 years
Definition
Girls: 100-110/61-68
Boys: 100-113/59-67
Term
BP 6 years
Definition
Girls: 104-114/67-75
Boys: 105-117/67-76
Term
BP 10 years
Definition
Girls: 112-122/73-80
Boys: 110-123//73-82
Term
BP 16 years
Definition
Girls: 122-132/79-86
Boys: 125-138/79-87
Term
Posterior Fontanel Closes
Definition
2-3 months
Term
Anterior Fontanel Closes
Definition
12-18 months
Term
Peripheral Visual Fields
Definition
Upward 50*
Downward 70*
Nasally 60*
Temporally 90*
Term
Teeth
Definition
Infants should have 6-8 teeth by 1 year of age
Term
# of Teeth
Definition
20 deciduous and 32 permanent
Term
Breasts (Females)
Definition
Typically develop between 10-14 years
Term
Heart Sounds
Definition
S1 louder at the apex; S2 louder at the base. S2, S3 splitting is normal
Term
Sucking and Rooting Reflex
Definition
Birth-4 months - elicited by stroking an infants cheek or the edge of an infants mouth
Term
Palmar Grasp
Definition
Birth-6 months - elicited by placing an object in an infant's palm
Term
Plantar Grasp
Definition
Birth-8 months - elicited by touching the sole of an infant's foot (toes curl downward)
Term
Moro Reflex (startle)
Definition
Birth-4 months - striking a flat surface or allowing the head and trunk to fall backward (arms and legs extend and abduct)
Term
Tonic Neck Reflex (fencer position)
Definition
Birth-3/4 months - elicited by turning an infants head to one side (extends the arm and leg on that side and flexes the arm and leg on the opposite)
Term
Babinski Reflex
Definition
Birth-1 year - elicited by stoking the outer edge of the sole of an infant's foot up toward the toes (fan upward and out)
Term
Stepping
Definition
Birth-4 months - elicited by holding n infant upright with his feet touching a flat surface
Term
Olfactory 1
Definition
Children - id smells through each nostril
Term
Optic 2
Definition
Infants - looks at face + tracks w/eyes
Children - intact visual acuity, peripheral vision, and color vision
Term
Oculomotor 3
Definition
Infants - blinks in response to light, pupils reactive to light
Children - has no nystagmus and PERRLA is intact
Term
Trochlear 4
Definition
Infants - looks at face and tracks with eyes
Children - has the ability to look down and in with eyes
Term
Trigeminal 5
Definition
Infants - has rooting and sucking reflex
Children - able to clench teeth together, detects touch on face with eyes closed
Term
Abducens 6
Definition
Infant - looks at face and tracks with eyes
Children - able to see laterally with eyes
Term
Facial 7
Definition
Infants - has symmetric facial movements
Children - ability to differentiate between salty and sweet on tongue, has symmetric facial movements
Term
Acoustic 8
Definition
Infants - tracks a sound, blinks in response to a loud noise
Children - does not experience vertigo, has intact hearing
Term
Glossopharyngeal 9
Definition
Infant - gag reflex
Children - gag reflex, able to taste sour sensations on the back of the tongue
Term
Vagus 10
Definition
Infant - has no difficulty swallowing
Children - speech clear, no difficulties swallowing
Term
Spinal Accessory 11
Definition
Infants - moves shoulders symmetrically
Children - equal strength of shoulder shrug
Term
Hypoglossal 12
Definition
Infants - no difficulties swallowing, opens mouth when nares are occluded
Children - tongue midline, able to move tongue in all directions
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