Guide — Maternal-Newborn
Newborn Assessment for Nurses
The newborn period (first 28 days of life) demands rapid, systematic assessment. This guide covers the APGAR score, normal vital sign ranges, primitive reflexes, head-to-toe physical assessment findings, and the warning signs that require immediate intervention.
11 min read · Maternal-Newborn
Educational use only. Neonatal assessment and care vary by gestational age, delivery method, and institutional protocol. Always follow current NRP guidelines, facility policies, and provider orders. This guide reflects general principles for nursing students and NCLEX preparation. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Overview
The transition from fetal to extrauterine life requires rapid cardiopulmonary adaptation. Lung fluid is expelled; pulmonary vascular resistance drops; the ductus arteriosus and foramen ovale begin to close. Nurses must quickly identify when this transition is not proceeding normally and initiate neonatal resuscitation (NRP) protocol.
Initial assessment occurs in the first minutes of life (APGAR scoring), followed by a systematic head-to-toe assessment within the first 2 hours.
APGAR Score
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (color) | Blue/pale all over | Blue extremities, pink body | Completely pink |
| Pulse (heart rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (reflex irritability) | No response | Grimace | Cry or cough/sneeze |
| Activity (muscle tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Slow, irregular | Strong cry |
Score Interpretation:
APGAR is scored at 1 and 5 minutes. If score remains <7 at 5 minutes, continue scoring every 5 minutes up to 20 minutes.
Newborn Vital Signs
| Parameter | Normal Range | Action if Abnormal |
|---|---|---|
| Heart rate | 110–160 bpm | <100: stimulate, PPV; >160: assess for distress, fever |
| Respiratory rate | 30–60 breaths/min | <30 or >60: assess for distress signs; oxygen per order |
| Temperature | 36.5–37.5°C (97.7–99.5°F) | Hypothermia: warm; fever: sepsis workup |
| SpO₂ (after stabilization) | ≥95% by 10 min of age | Below NRP target table: supplemental O₂, PPV |
| Blood glucose | ≥45 mg/dL after 4 hours of age | Symptomatic or <25: IV dextrose; <45: early feeding |
Newborn Reflexes
| Reflex | Stimulus | Normal Response | Disappears |
|---|---|---|---|
| Moro (startle) | Sudden head drop | Arms abduct, extend, then embrace; cry | 3–6 months |
| Rooting | Touch to cheek | Turns head toward stimulus, opens mouth | 3–4 months |
| Sucking | Object in mouth | Rhythmic sucking movements | 3–4 months (voluntary) |
| Palmar grasp | Finger placed in palm | Curls fingers around object | 3–4 months |
| Babinski | Stroke lateral foot sole | Great toe dorsiflexion, fan toes (normal in newborns) | 12–24 months |
| Stepping | Feet touch surface | Alternating stepping movements | 2–3 months |
Absence of expected reflexes or asymmetrical response warrants neurologic evaluation.
Physical Assessment
Head:
- Caput succedaneum: scalp edema crossing suture lines — normal, resolves in days
- Cephalohematoma: blood between periosteum and skull, does NOT cross suture lines — resolves in weeks; monitor for jaundice
- Fontanelles: anterior (diamond-shaped, closes 12–18 months); posterior (triangular, closes 2–3 months)
- Molding: overlapping of skull bones — normal, resolves in days
Eyes/Ears/Nose:
- Subconjunctival hemorrhage from birth pressure — benign, resolves in weeks
- Ears at or above eye level — low-set ears associated with chromosomal anomalies
- Nares patent bilaterally — choanal atresia presents with cyanosis relieved by crying
Skin:
- Vernix caseosa: white, cheesy coating — protective, rub in gently
- Lanugo: fine hair on shoulders/back — normal in preterm; resolves with maturity
- Milia: white papules on nose/chin — plugged sebaceous glands, benign
- Erythema toxicum: red blotchy rash with white/yellow centers — benign, resolves days 1–2
- Mongolian spots: blue-gray pigmentation, usually lumbosacral — common in darker-skinned neonates; document to distinguish from bruising
- Physiologic jaundice: appears after 24 hours; peak days 3–5; assess with transcutaneous bilirubin
- Pathologic jaundice: appears within first 24 hours — requires immediate evaluation
Abdomen/Genitalia/Extremities:
- Umbilical cord: 2 arteries + 1 vein; single umbilical artery associated with renal anomalies
- Meconium: first stool within 24 hours; failure to pass within 48 hours = Hirschsprung disease risk
- First void within 24 hours; 6–8 wet diapers/day by day 4–5 indicates adequate hydration
- Ortolani/Barlow maneuver: assess for developmental dysplasia of the hip (DDH)
- Count fingers and toes; assess for polydactyly, syndactyly
Warning Signs — Escalate Immediately
- Respiratory rate >60/min, grunting, nasal flaring, intercostal or subcostal retractions, central cyanosis
- Heart rate <100 or >180 bpm persisting beyond transition period
- Temperature instability: hypothermia (<36.5°C) or fever (>38°C)
- Jaundice within first 24 hours — always pathologic; requires urgent bilirubin workup
- Jitteriness or seizure activity — assess glucose; may indicate hypoglycemia, hypocalcemia, or infection
- Absent or asymmetrical Moro reflex — may indicate birth injury, nerve damage, or CNS abnormality
- Failure to pass meconium within 48 hours
- Signs of infection: poor feeding, lethargy, temperature instability, bulging fontanelle
NCLEX Pearls
- APGAR score of 7–10 is normal; score <7 at 5 minutes requires continued assessment and support
- Jaundice in the first 24 hours is pathologic; after 24 hours is physiologic (peak days 3–5)
- Caput succedaneum crosses suture lines; cephalohematoma does NOT — key NCLEX distinction
- Mongolian spots must be documented — distinguish from bruising or signs of abuse
- First void within 24 hours; first meconium stool within 24–48 hours — failure to do so is abnormal
- Babinski reflex (upgoing great toe) is NORMAL in newborns; abnormal in adults
- Choanal atresia: neonate turns blue at rest, pink when crying — obstruct nares test
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with American College of Obstetricians and Gynecologists (ACOG) · AWHONN · American Academy of Pediatrics (AAP) — newborn. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →