THE INFANT AT 4 WEEKS FOLLOWING BIRTH

THE INFANT AT 4 WEEKS FOLLOWING BIRTH - Activity/Rest...

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THE INFANT AT 4 WEEKS FOLLOWING BIRTH INFANT ASSESSMENT DATA BASE Review prior assessments for identified risk factors. Activity/Rest Infant sleep pattern well-established Circulation Heart rate ranges from 80–150 bpm at rest, with average rate of 120 bpm. BP obtained by using flush technique at wrist ranges from 48–90 mm Hg, with a mean of  67 mm Hg; at ankle, 38–56 mm Hg, with a mean of 61 mm Hg. Ego Integrity Regards faces, especially parents’ faces, intently; may demonstrate beginning of social smile Elimination Urine pale or straw-colored, with output of 6–10 wet diapers per day Abdomen soft, nondistended with bowel sounds present Individual bowel elimination pattern established, dependent on type of feeding Food/Fluid Makes comfort noises during feeding, or may make small, throaty noises Feeding generally 5–8 times per 24-hr period Height gain 2.5 cm (1 in) monthly for first 6 mo Weight gain of 3–5 oz/wk for first 6 mo Drooling absent until 2–3 mo of age, when salivary glands begin to function Neurosensory Beginning to differentiate cry in relation to pain, discomfort, or hunger; uses cry to signal needs; quiets when picked  up. Head circumference increases 1.5 cm ( 1 2  in) monthly for first 6 mo. Fontanels palpable and soft; posterior fontanel closes at 6 wk of age. Tears present, with tear glands beginning to function at 2–4 wk of age. Primitive reflexes present with strong, bilaterally equal responses. Doll’s eye and dance reflexes fading. Crawling movements when prone. Lifts head momentarily from bed while on abdomen, turns head from side to side when prone. Demonstrates tonic neck reflex when supine. Marked head lag when pulled from lying to sitting position (back is uniformly rounded); absence of head control in  sitting position. Strong grasp reflex: Hand closes on contact with object. Responds to environmental stimuli: Bright objects (which are best viewed 8–12 in from face), sound, and touch. Pain/Discomfort Continuation of pain and cramping associated with colic may be reported. Respiration Signs of aspiration (continued regurgitation associated with reverse peristalsis and immature or relaxed cardiac  sphincter)
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Safety Axillary temperature stable between 97.7°F–98.6°F (36.5°C–37.0°C) Perineal area clean and free of rashes DIAGNOSTIC STUDIES Testing dependent on individual findings, risk factors.
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This note was uploaded on 02/01/2011 for the course PNR 182 taught by Professor Toole during the Spring '10 term at Orangeburg-Calhoun Technical College.

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THE INFANT AT 4 WEEKS FOLLOWING BIRTH - Activity/Rest...

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