Chapter 30
Assessing Newborns and Infants
Growth and Development
Motor development: gross and fine
Sensory perception: vision, hearing, and others
Cognitive and language development
Psychosocial, psychosexual, moral
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Question #1
Is the following statement true or false?
The sense of smell develops fully by the sixth month in
infants.
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Answer to Question #1
False.
The sense of smell is fully developed at birth.
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Collecting Objective Data
Preparing the client
Equipment
o Denver Development Kit
o Measuring tape, ophthalmoscope
o Otoscope, scale, stethoscope, thermometer
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Initial Newborn Assessment
Apgar score
Vital signs
Measurements: weight, length, head circumference,
chest circumference
Gestational age: neuromuscular and physical maturity
Newborn reflexes
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Question #2
Which reflex is elicited by touching the newborn’s upper or
lower lip or cheek with a gloved finger or sterile nipple?
A. Plantar grasp
B. Palmar grasp
C. Moro
D. Rooting
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Answer to Question #2
D. Rooting.
Rooting reflex is elicited by touching the upper or lower lip
or cheek. Palmar reflex is elicited by pressing one’s fingers
against the palmar surface of the hand. Plantar reflex is
elicited by touching the ball of the foot. Moro reflex is
elicited by startling the baby with a position change or
sudden stimulation.
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Subsequent Physical Assessment #1
Head-to-toe examination with developmental screening
General appearance and behavior
Developmental assessment
Vital signs: temperature, apical pulse, blood pressure,
and respiration
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Question #3
Is the following statement true or false?
The apical pulse is at the 5th intercostal space in infants.
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Answer to Question #3
False.
The apical pulse is at the 4th intercostal space in infants
until the age of 7 years, when it drops to the 5th.
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Subsequent Physical Assessment #2
Measurements: height, weight, head circumference
Skin, hair, and nails
Head, neck, and cervical lymph nodes
Eyes
Ears
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Subsequent Physical Assessment #3
Mouth, throat, nose, and sinuses
Thorax
Breasts
Heart
Abdomen
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Subsequent Physical Assessment #4
Male genitalia
Female genitalia
Anus and rectum
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Subsequent Physical Assessment #5
Hands, feet, arms, legs
Musculoskeletal assessment
o Ortolani maneuver
o Barlow maneuver
Assess spinal alignment, joints, and muscles
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Diagnostic Reasoning
Nursing diagnosis
o Actual
o Risk
o Wellness
Collaborative problems
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