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I. GENERAL MEASUREMENTS
a. Age Term = start of 38th wk. end of 42nd preterm = before end of 37th wk.
week. posterm = after end of 42nd wk.
c. Length 18-20.5 in
45-52.3 cm
III. EYES
c. Reaction to Light Pupils equal in size, round and Pupils unequal, restricted, dilated,
reactive to light. May turn toward fixed
soft light.
e. Evidence of sight Focuses and follows by 15 min of Does not respond to light, focus or
age. See above, reaction to light. follow.
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation
f. Eyelids Size and movement symmetric. Does not respond to light, focus, or
Blink reflex. Edema from follow.
prophylaxis. Eyes on a parallel plane.
IV. EARS
V. NOSE Midline
1. Sucking
2. Swallow
VII. NECK
VIII. CHEST
IX. RESPIRATIONS
c. Breath Sounds No sounds heard without stethoscope. Grunting, rales, rhonchi, wheeze (with
or without stethoscope)
d. Muscular activity involved Simultaneous rise and fall of chest Subcostal and substernal retractions.
and abdomen. Diaphragmatic and Flaring of nares. Chin tug.
abdominal breathing.
X. PULSE
d. Fingers
XII. ABDOMEN
XIV. GENITAL-URINARY
b. Type Mucoid/white
Possible Major Deviations and
Assessment Textbook Information Complications Infant Observation
c. Voidings
XV. RECTUM
b. Stools
XVI. HIPS
XVII. BACK
XIX. SKIN
d. Characteristics
XX. TEMPERATURE
XXI. REFLEXES
a. Local
7. Yawn Spontaneous.
b. Generalized
XXII. CRY
c. Parent-infant interaction Turns head and focuses when interested. No focus on person handling.
Coordinates body movement to parent’s
voice and body movement.