Newborn Assessment

Immediate Care of the Newborn

Simultaneous activities:

– Assess and stabilize

– Evaluate if cardiac/respiratory help needed for baby to initiate breathing

            S/S respiratory distress:

                        – grunting- noise on exhalation           Retractions

                        – nasal flaring                                      Cyanosis

                        – Lack of respiratory effort

– Respiratory- suction secretions from the airway.

– Cardiac: Always take apical pulse for 1 minute- 4th intercostals space a little left of the midclavicular line

            – <100= bad. Normal= 120-160

– Dry and wrap in blanket-

– Newborns can’t shiver- problem regulating/ maintaining temperature.

– Heat loss and cold stress can cause hypoglycemia in newborn

– Apgar at 1 and 5 minutes

– Visual inspection:

            – posture, muscle tone of extremities, state, color, gross abnormalities (congenital malformations)

– Take and record time of birth




SIGN Score 0 Score 1 Score 2
Heart Rate Absent Below 100 per minute Above 100 per minute
Respiratory Effort Absent Weak, irregular, or gasping Good, crying
Muscle Tone Flaccid Some flexion of arms and legs Well flexed, or active movements of extremities
Reflex/Irritability No response Grimace or weak cry Good cry
Color Blue all over, or pale Body pink, hands and feet blue Pink all over


If <5 resuscitative measures may be necessary.


Vital Signs

Temperature: 36.5 (97.7) to 37.2 (98.9)

Pulse: 100-180 à Checked at 5th intercostals space- midclavicular line

Respirations: 30-60/minute


Other nursing responsibilities in L & D

– Identify baby (ID band on child before leaving labor room) and footprints

– “Eyes and Thighs”- 2 medications need to be given: Put in Vastus Lateralis muscle

            1- Vitamin K- 25 gauge 5/8 inch needle- given for clotting

            2- Erythromycin Ophthalmic- put in eyes – for Chlamydia and gonorrhea in birth canal.


Benefits of skin to skin contact:

– temperature regulation- babies who have skin to skin contact immediately after birth can better regulate their temp at 1 hour

– Decreased crying

– Enhanced breastfeeding

– Increased milk supply

à can put baby on mother’s abdomen to do assessment


Newborn Skin Issues

Milia– little white ‘dots’ on nose, forehead and chin or mouth. Caused by blocked sebaceous glands. Will go away completely- totally benign

Newborn Rash– will spontaneously go away by 3 weeks

Vernix–  is the waxy or “cheesy” white substance found coating the skin. It is very good for the newborn skin- rub it in- will absorb naturally. Don’t put products on it.

Mongolian Spots– dark spots- collection of capillaries. Looks like a bruise.  Completely benign. Most common on dark-skinned babies (black, Asian).

Lanugo– fine hair most commonly found on preterm neonates. Tends to be most on back and chest. More premature=more lanugo.

Acrocyanosis– cyanosis in hands and feet. Takes a few days to go away.

Nevi– “stork bite”- will blanch when touched- will fade by 2 y/o. Collection of immature blood vessels.

Strawberry Hemangioma- will be textured (rough, raised, bumpy). Will appear later- after birth and will fade by 9 y/o.

Port-Wine Stain– Most often on head and neck. Will not change colors when touched. Tx most often laser surgery.


Make sure fontanels aren’t sunken (dehydration) or bulging (increased ICP).

Molding – reassure parents head will go back to ‘round’ shortly after birth. Sign to pay special attention to neuro exam.


Common Problems

Caput Succedaneum– swelling in a diffuse area

            – edema                                               – appears at birth, disappears in several days

            – Vague, poorly defined outline          -***Crosses suture lines***

Cephalhematoma– more significant

            – blood between skull and periosteum            – Appears several hours after birth, size increases

            – Well defined outline                                     – **Never crosses suture lines- will follow lines**

            – Risk for jaundice, skull fracture, intracranial bleeds


Vital Signs:

            Temp- 36.5- 37.2 C (97.7-98.9) normal- Take axillary- will stabilize in 8-12 hr.

            Pulse- 120-160 (100-180 may be normal depending on activity level)

                        4th intercostal space, midclavicular line

            Respirations- 30-60

            Blood Pressure- 60-80/ 40-50



Evaporation: When wet surface on the baby is exposed to air – need to dry the infant after birth and after baths, especially the head.

Conduction: When the newborn comes into direct contact with something colder than them – Do not place them on a cold surface. Warm objects first that will touch the baby. Skin to skin contact prevents this loss.

Convection: Heat transfers to air around the infant such as AC or people walking around creating currents – Need to keep the newborn out of drafts, maintain a warm environment, warm oxygen before administering.

Radiation: Transferring of heat to cooler objects not in contact with the newborn – newborns lose their heat by being placed near a cold window. Place crib or play area away from windows.

***Test***Weight- Newborns lose 5-10% in the first 5 days- should regain birth weight by 2 weeks

            à if loose 7% this is a red flag that should be evaluated.

Renal- newborn should void within 24 hours

            Urine output scant during first few days as baby adjusts to feedings

                        Once in 1st 24 hours, Twice in 2nd 24 hours, 3x in 3rd 24 hours

                        Increases on day 3-4 when milk comes in, then 6-8 voids/24 hours

            Stools- Meconium at firstà progressive changes in appearance and pattern

                        Indication of adequate nutritional intake:

                        1st stool at 48 hours of age; 3 stools per 24 hours once milk comes in


Jaundice: Cephalocaudal pattern

            Total Bilirubin-

                        Conjugated (direct)- attached to albumin- can be excreted

Unconjugated (indirect)- causes problems- isn’t attached to protein (free floating)- could go into the brain.

         Measured in lab with a heel stick

Physiologic Jaundice or Hyperbilirubinemia– onset after 24 hours of age

                        Peaks around day 4; subsides at 4-6 days

                        Benign in normal- healthy term newborn

                        Indirect bilirubin (normal) equal to or less than 12mg/dl by day 3

                                                                                     15-17 in preemie

                        Early (within 1 hour) and frequent feedings may help

Breastfeeding Jaundice– Early onset (within first few days) due to lack of adequate intake. Counsel mother to put baby to breast every 3 hours – even if sleeping.  This stimulates stool to excrete excess bilirubin.

Breastmilk Jaundice– Late onset- Hyperbilirubinemia beyond 1st week- peaks at 2 weeks.

Pathologic Jaundice– Jaundice <24 hours. Usually caused by ABO incompatibility.  Increases >0.5 mg/dl/hr. Peaks at >13 mg/dl/hr in term infant.

Associated with anemia and enlarged liver and spleen. If it persists past day 7- it can progress to kernicterus or bilirubin encephalophy (usually at bilirubin level >25). s/s= lethargy, hypotonic, poor suck.

Tx: Phototherapy

            Monitor Temp                         Eye patches

            Turning q2 hours                     Monitor I & O

            Shield Genitals (boys)             Observe skin color                             

Risk factors for Hyperbilirubinemia:

            ABO Incompatibility              Preterm

            Postterm                      Traumatic birth (bruising will cause RBC’s to lyse)



– Infant retains passive immunity for approx 3 months; longer if breastfeeding.

IgG- only immunoglobin that crosses placenta

IgM- 1st immunogloubin newborn makes

IgA- Secreted in colostrum – immunity to GI and respiratory infections if breastfed



Rooting and Sucking                          Stepping or Walking

Grasp – Palmar and plantar                 Moro

Babinski- on sole of foot, beginning at heel, stroke upward along side of sole then move finger across ball of foot- All toes hyperextend- with dorsiflexion of big toe.

Tonic Neck     


Sleep-Wake States

            Sleep States

Deep Sleep- Regular breathing

Light Sleep- REM, body movement, variable breathing

Wake States

Drowsy- intermediate, state before waking

Quiet alert- optimal state of arousal- Easiest to interact- highly receptive

Active alert- high movement, fussy state

Crying- communication state


Behavioral Adaptation after birth

First period of reactivity: Transitions to extrauterine life. Very alert, irregular respiratory effort, irregular CV, etc. promote bonding, encourage breastfeeding.

Period of inactivity- Deep sleep- lasts 1 to 1 ½ hours. Can not breastfeed during this time.

Second Period of reactivity- alert, responsive. Lasts a few minutes to hours.


PKU- Causes Mental retardation- test done on day 2-3. Tx: diet low in Phenylamine.


Danger Signs:

            Abnormal fontanel size- or bulging or sunken fontanel

            Respiratory system signs:

Tachypnea (TTN- transient tachypnea of the newborn)- when newborn takes too long to transition to extrauterine life- will go away, but needs care until then.

Nasal Flaring                                       Expiratory grunting

Retractions                                          Rales and Rhonchi

Asynchronous breathing movements  Cyanosis

Decreased/absent breath sounds         Acidosis

Hypotension and shock                      Hypercapnia


Preterm- before 37 weeks

            Immaturity in all systems

            Risks: Excessive heat loss- thin skin, decreased subq fat, increased BSA

Vulnerability to hyperoxic injury (too high O2 level can damage retina causing blindness).

Immature lungs and diminished respiratory drive

Immature brain that is prone to bleeding

Vulnerability to infection

Necrotizing enterocolitis- part of intestine dies- most serious problem of preterm infant. s/s- not passing stool, increased vomiting, increasing abd. Distension, no bowel sounds.

            Nursing: Monitor and control blood sugar

Monitor for apnea, tachycardia, bradycardia, or O2 desaturations- intervene promptly.

Monitor and control oxygenation and ventilation

Consider delaying feeding if perinatal compromise is significant

Increased suspicion for infection

Control noise and light (cover isolette, decrease noise level)


Small For Gestational Age (SGA)- 2 types

Intrauterine growth retardation (IUGR)- wt. below 10th percentile

1- Symmetric- caused by an early insult to the fetus during pregnancy (ie: drug use, rubella)

            Deficiency in cell numbers

            Head circumference below 10th percentile

            Small brain- child never catches up- mental retardation

2- Asymmetric- Caused by an insult late in the pregnancy

            Atrophy in cells that are already formed by this time                       

            Diminished cell size but cell numbers are normal

            Large head (disproportionately)

            Long body with little fat, looks emaciated

            Postnatal growth and development rapid- can catch up if caught early.


Large for Gestational Age (LGA)- wt above 90th percentile or over 8lb14oz

            Risk factors: Genetics, maternal weight gain, gestational diabetes

Potential for trauma (shoulder dystocia, clavicle fx, palsies, skull fx, facial nerve damage) if delievered vaginally-> may necessitate c-section.

Also at risk for hypoglycemia


9 thoughts on “Newborn Assessment”

  1. you’re amazing! thank you so much! I needed clarification on so much and this covered it all 🙂

  2. I can’t tell you how grateful I am for this blog. This is beyond what I expected and I thank you so much for it!

  3. I love this page and site; it helps nursing students to the max please keep it up. It gives a great breakdown of material and great study questions!!!

  4. I needed to review my class not for the exam,it coer it all in a very simple way. Thank you so much!
    Please keep it up?
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  5. Thanks so much for your support
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    Simple, precise and easily understood notes..

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