General appearance

a. Does child have a recognizable congenital syndrome (eg, Down syndrome)? What is general posture? Children with hypotonia often assume a frog-leg position and have positional plagiocephaly because of their usual positioning on back with little head movement.

b. Any signs of sepsis? Check for decreased skin perfusion, tachycardia, and prolonged capillary refill.

2. Vital signs and respirations. Is the airway protected? Check gag reflex. What is the respiratory effort, and is it effective? Check for grunting, flaring retractions, paradoxical respiratory movements, and overall aeration. Confirm with pulse oximetry.

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