The first 24 hours after birth is a critical period of transition from intrauterine to extrauterine life. Proper assessment and care during this time can significantly influence the newborn’s health outcomes. These notes provide comprehensive guidance on newborn assessment and essential care practices.
1. Immediate Assessment
First Assessment occurs immediately after birth and focuses on determining if the newborn requires resuscitation or can transition normally.
APGAR Score
| Parameter | 0 Points | 1 Point | 2 Points |
|---|---|---|---|
| Appearance (Color) | Blue/Pale | Acrocyanosis (blue extremities, pink body) | Completely pink |
| Pulse Rate | Absent | Below 100 bpm | Above 100 bpm |
| Grimace (Reflex Irritability) | No response | Grimace/weak cry when stimulated | Vigorous cry, cough, or sneeze when stimulated |
| Activity (Muscle Tone) | Limp/Flaccid | Some flexion of extremities | Active movement, flexed arms and legs |
| Respiration | Absent | Slow/Irregular | Good, crying |
Timing: APGAR score is assessed at 1 minute and 5 minutes after birth, and may be repeated at 10, 15, and 20 minutes if the score remains below 7.
Interpretation:
- 7-10: Normal
- 4-6: Moderately depressed
- 0-3: Severely depressed
2. Complete Physical Assessment
Mnemonic: HEAD TO TOE Assessment
Head, Face, and Neck
Ears and Eyes
Airway and Mouth
Digestive System
Thorax and Lungs
Organs (Heart, Abdomen)
Temperature and Vital Signs
Organ of Generation (Genitalia)
Extremities and Spine
Head-to-Toe Assessment Guide
General Appearance
- Body proportions
- Posture: Flexed, relaxed
- Movements: Symmetrical, purposeful
- Skin color: Pink with possible acrocyanosis
- Gestational age appearance
Measurements
- Weight: 2500-4000g (5.5-8.8 lbs)
- Length: 45-55 cm (18-22 inches)
- Head Circumference: 32-38 cm (12.5-15 inches)
- Chest Circumference: 30-35 cm (12-14 inches)
Vital Signs
- Heart Rate: 120-160 beats/minute
- Respiratory Rate: 40-60 breaths/minute
- Blood Pressure: 65-95/30-60 mmHg
- Temperature: 36.5-37.5°C (97.7-99.5°F)
System-by-System Assessment
Head and Skull
- Shape: Round, symmetrical (may be temporarily misshapen from birth process)
- Fontanelles:
- Anterior: Diamond-shaped, 2-3 cm
- Posterior: Triangular, 0.5-1 cm
- Both should be soft, flat, and pulsatile
- Assess for: Caput succedaneum (crosses suture lines), cephalohematoma (does not cross suture lines), molding
Face
- Symmetry of features
- Facial expressions
- Bruising or trauma from delivery
Eyes
- Position and spacing
- Pupillary response to light
- Subconjunctival hemorrhage (common and benign)
- Red reflex (present and symmetrical)
- Assess for discharge or excessive tearing
Ears
- Position: Top of pinna should align with outer canthus of eye
- Structure and formation
- Response to sounds
Nose
- Patency of nostrils (newborns are obligate nose breathers)
- Position and shape
- Assess for flaring (respiratory distress)
Mouth
- Lips: Color, symmetry, cleft lip
- Palate: Intact, no cleft
- Tongue: Size, movement, frenulum (assess for tongue-tie)
- Sucking reflex
- Saliva: Quantity and consistency
Neck
- Short with skin folds
- Range of motion
- Assess for masses, webbing, or torticollis
Chest and Lungs
- Shape: Circular, symmetrical
- Nipples: Position, size, possible physiologic breast engorgement (due to maternal hormones)
- Breathing pattern: Regular, abdominal breathing predominates
- Auscultation: Clear breath sounds bilaterally
- Assess for: Retractions, grunting, nasal flaring, asymmetrical chest movement
Cardiovascular
- Heart rate: 120-160 beats/minute
- Auscultation: Clear S1, S2; innocent murmurs common in first 24 hours
- Pulse: Brachial, femoral, pedal pulses
- Capillary refill: Less than 3 seconds
- Assess for: Cyanosis, especially central cyanosis
Abdomen
- Shape: Rounded, soft
- Umbilical cord: 3 vessels (2 arteries, 1 vein), clamped, no bleeding or discharge
- Bowel sounds: Present within 15-30 minutes after birth
- Liver: May be palpable 1-3 cm below right costal margin
- Assess for: Distention, masses, visible peristalsis
Genitourinary
- Male:
- Penis: Size, position of urethral meatus (rule out hypospadias/epispadias)
- Testes: Both descended into scrotum
- Scrotum: Size, rugae, possible edema or discoloration
- Female:
- Labia: Size, symmetry
- Clitoris: Size
- Vaginal discharge: White mucoid or blood-tinged discharge (pseudomenstruation) may be normal
- Urine output: First void within 24 hours
Musculoskeletal
- Extremities: Symmetry, movement, flexibility
- Spine: Straight, intact, no dimples or hair tufts
- Hands and feet: Digits, creases, position
- Clavicles: Intact, no crepitus or asymmetry
- Assess for: Fractures, dislocations, congenital abnormalities
Neurological
- Tone: Good flexion of all extremities
- Reflexes:
- Moro: Symmetrical extension and abduction followed by flexion and adduction of arms when startled
- Rooting: Turns head toward stimulus on cheek or mouth
- Sucking: Strong, coordinated
- Palmar grasp: Grasps finger when palm is stimulated
- Stepping: Walking motion when feet touch a surface
- Babinski: Fanning of toes with dorsiflexion of big toe when sole is stroked
Skin
- Color: Pink with possible acrocyanosis
- Texture: Smooth, elastic
- Common findings: Vernix caseosa, lanugo, milia, erythema toxicum, Mongolian spots
- Assess for: Birthmarks, rashes, bruising, petechiae, jaundice
Note: Always document all findings accurately, including normal and abnormal findings. Report any concerning findings to the healthcare provider immediately.
3. Essential Newborn Care
Essential Newborn Care Components
Thermoregulation
Respiratory Support
Nutrition
Infection Prevention
Umbilical Cord Care
Eye Care
Thermoregulation
Rationale: Newborns are at high risk for heat loss due to:
- High body surface area to weight ratio
- Limited subcutaneous fat
- Immature temperature regulation
- Limited ability to produce heat through shivering
Four Mechanisms of Heat Loss:
| Mechanism | Description | Prevention |
|---|---|---|
| Evaporation | Heat loss when wet skin dries (amniotic fluid) | Dry baby thoroughly after birth, especially head; remove wet linens |
| Conduction | Heat loss when placed on cold surfaces | Pre-warm surfaces, use warmed blankets/linens |
| Convection | Heat loss from air currents across skin | Avoid drafts, minimize exposure, use caps |
| Radiation | Heat loss to cooler objects not in direct contact | Keep newborn away from cold windows/walls, use radiant warmers |
Nursing Interventions:
- Maintain delivery room temperature at 24-26°C (75-78°F)
- Immediate skin-to-skin contact with mother when possible
- Cover newborn’s head with cap (30% of heat loss occurs through head)
- Monitor axillary temperature (normal: 36.5-37.5°C/97.7-99.5°F)
- Delay bathing for at least 24 hours to prevent hypothermia
- Use pre-warmed radiant warmers for procedures
- Wrap newborn in pre-warmed blankets when not in skin-to-skin contact
- Initiate kangaroo care when appropriate
Warning: Hypothermia can lead to hypoglycemia, metabolic acidosis, respiratory distress, and poor feeding. Signs include cold extremities, mottled appearance, lethargy, poor feeding, and respiratory distress.
Respiratory Support
Rationale: Lungs must clear fetal lung fluid and establish regular breathing patterns after birth.
Normal Newborn Respiratory Characteristics:
- Rate: 40-60 breaths/minute
- Pattern: Primarily abdominal breathing
- Regular rhythm with occasional periodic breathing
- Clear breath sounds bilaterally
- No retractions, grunting, or nasal flaring
Nursing Interventions:
- Position newborn with neck slightly extended (sniffing position)
- Clear secretions from nose and mouth as needed (bulb syringe)
- Avoid excessive suctioning which can cause bradycardia
- Monitor respiratory rate, effort, and pattern
- Recognize signs of respiratory distress:
- Tachypnea (>60 breaths/minute)
- Nasal flaring
- Grunting
- Retractions (intercostal, subcostal, suprasternal)
- Central cyanosis
- Maintain proper positioning during feeds to prevent aspiration
- Promote skin-to-skin contact which stabilizes respiratory patterns
Nutrition
Breastfeeding:
- Initiate breastfeeding within first hour of life when possible
- Ensure proper latch:
- Wide-open mouth
- Lips flanged outward
- More areola visible above than below
- Chin touching breast
- Feed on demand (8-12 times per 24 hours)
- Assess effectiveness:
- Audible swallowing
- Soft breasts post-feeding
- Sufficient wet/soiled diapers
- Benefits:
- Optimal nutrition
- Immune protection
- Promotion of bonding
- Support of infant gut microbiome
Formula Feeding (when necessary):
- Use iron-fortified infant formula
- Feed approximately 15-30 ml (½-1 oz) every 2-3 hours initially
- Hold infant semi-upright
- Allow pauses during feeding
- Burp after every ½-1 ounce
Monitoring Adequate Intake:
| Day of Life | Expected Wet Diapers | Expected Stool Diapers |
|---|---|---|
| 1 | 1-2 | Meconium (black, tarry) |
| 2 | 2-3 | 1-2 (transitioning from meconium) |
| 3 | 3-4 | 2-3 (greenish-brown transitional) |
| 4 | 4-6 | 3-4 (yellowish, seedy if breastfed) |
| 5+ | 6+ | 3-5 (yellow, soft if breastfed; firmer if formula-fed) |
Note: Watch for signs of feeding problems including poor latch, prolonged feeding sessions (>45 minutes), falling asleep immediately after latching, minimal swallowing sounds, and inadequate output.
Infection Prevention
Rationale: Newborns are susceptible to infections due to immature immune systems.
Nursing Interventions:
- Hand Hygiene:
- Strict hand hygiene before any contact with newborn
- Educate family members and visitors on handwashing
- Equipment:
- Use clean or sterile equipment as appropriate
- Avoid sharing personal items between infants
- Isolation:
- Restrict contact with ill visitors or staff
- Implement isolation procedures for infected infants
- Vaccinations:
- Hepatitis B vaccine within 24 hours of birth
- Monitor for signs of infection:
- Temperature instability (hypo- or hyperthermia)
- Poor feeding or feeding intolerance
- Lethargy or irritability
- Respiratory distress
- Skin changes: rashes, pustules, erythema
Umbilical Cord Care
Rationale: Proper cord care prevents infection and promotes healing.
Nursing Interventions:
- Keep cord clean and dry
- Clean around the base with sterile water or as per facility protocol
- Allow cord to dry naturally (avoid covering with diaper)
- Fold diaper below umbilical stump
- Sponge bathe until cord falls off (typically 7-14 days)
- Monitor for signs of omphalitis (cord infection):
- Redness or swelling at base
- Foul smell
- Purulent discharge
- Delayed separation (>3 weeks)
- Teach parents proper cord care techniques
Cord Care Options:
| Method | Description | Consideration |
|---|---|---|
| Dry Care | Keep clean and dry with no topical applications | WHO recommended; simplest approach |
| Chlorhexidine | Application of chlorhexidine solution | Recommended in high-risk settings or high neonatal mortality areas |
| Alcohol | Cleaning with alcohol swabs | May delay cord separation; less commonly recommended now |
Eye Care
Rationale: Prophylaxis against ophthalmia neonatorum (gonococcal or chlamydial conjunctivitis).
Nursing Interventions:
- Administer prophylactic eye medication within 1-2 hours of birth:
- Erythromycin ophthalmic ointment 0.5% (most common in US)
- Alternative: Tetracycline ophthalmic ointment 1%
- Apply a thin line of ointment along lower conjunctival sac of each eye
- Document administration
- Wipe excess ointment from outside of eye (do not rinse eyes)
- Monitor for signs of chemical conjunctivitis (redness, mild swelling)
- Provide parent education about normal appearance and expected mild irritation
Skin Care
Rationale: Newborn skin is sensitive and vulnerable to damage and infection.
Nursing Interventions:
- First Bath:
- Delay first bath for at least 24 hours after birth
- Maintain thermoregulation during bathing
- Use warm water (37-38°C/98.6-100.4°F)
- Use mild, pH-neutral, fragrance-free soap
- Limit bath time to 5-10 minutes
- Routine Skin Care:
- Clean diaper area with each diaper change
- Use water or mild wipes without alcohol or fragrance
- Apply barrier cream if redness develops
- Keep skin folds dry and clean
- Avoid excessive products on skin
- Monitor for:
- Diaper dermatitis
- Excessive dryness or peeling
- Rashes or skin irritations
- Signs of infection
4. Newborn Nursing Care Plan
| Nursing Diagnosis | Interventions | Expected Outcomes |
|---|---|---|
| Risk for Ineffective Thermoregulation related to immature temperature regulation and transition to extrauterine environment |
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| Risk for Impaired Gas Exchange related to transition from fetal to newborn circulation and lung expansion |
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| Risk for Infection related to immature immune system and exposure to pathogens |
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| Risk for Ineffective Breastfeeding related to infant’s inexperience and maternal factors |
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| Risk for Impaired Parent-Infant Attachment related to situational stressors or knowledge deficit |
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5. Parent Education
Mnemonic: NEWBORN CARE Education Topics
Nutrition (breast/formula feeding)
Elimination patterns
Warmth and temperature regulation
Bathing and skin care
Ongoing assessment (normal vs. abnormal)
Respiratory patterns and positioning
Navigating newborn behavior
Cord care
Appropriate clothing
Recognizing illness signs
Emergency situations and when to call provider
Key Education Points
When to Call Healthcare Provider:
- Temperature above 38°C (100.4°F) or below 36.5°C (97.7°F)
- Poor feeding (refuses 2 consecutive feedings)
- Fewer than 6 wet diapers in 24 hours after day 4
- Vomiting (not just spitting up)
- Diarrhea (watery, green stools)
- Inconsolable crying or unusual lethargy
- Yellowing of skin/eyes that extends to abdomen, arms, or legs
- Signs of infection around umbilical cord
- Difficult or rapid breathing
- Blue color around lips or skin
Safe Sleep Practices:
- Always place baby on back to sleep
- Use firm, flat sleep surface with fitted sheet
- Room-sharing recommended for at least 6 months
- No co-sleeping/bed-sharing
- Keep soft objects, loose bedding out of sleep area
- Maintain comfortable room temperature (68-72°F/20-22°C)
- Consider offering pacifier at nap/bedtime after breastfeeding established
- Avoid overheating
- No smoking around baby
Follow-up Care:
- First pediatrician visit typically 3-5 days after birth
- Schedule follow-up visits as recommended
- Discuss screening tests (hearing, metabolic)
- Review immunization schedule
- Discuss growth and development expectations
6. Summary
Newborn Assessment and Care Overview
Initial Assessment (APGAR)
Complete Physical Assessment
Essential Newborn Care
Parent Education
Ongoing Assessment & Follow-up
Key Takeaways:
- Thorough assessment of the newborn is crucial for identifying normal findings and potential complications
- The APGAR score provides a quick assessment of newborn adaptation to extrauterine life
- Essential newborn care focuses on thermoregulation, respiratory support, nutrition, infection prevention, cord care, eye care, and skin care
- Parent education is a vital nursing responsibility to ensure safe and appropriate care continues at home
- Early identification of deviations from normal allows for prompt intervention and improved outcomes
- Documentation of all assessments and interventions is crucial for continuity of care
7. References
- World Health Organization. (2017). WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Committee. World Health Organization.
- American Academy of Pediatrics. (2022). Caring for Your Baby and Young Child: Birth to Age 5. 7th edition.
- Association of Women’s Health, Obstetric and Neonatal Nurses. (2018). Neonatal skin care: Evidence-based clinical practice guideline. Washington, DC: AWHONN.
- Hockenberry, M. J., & Wilson, D. (2018). Wong’s nursing care of infants and children. Elsevier Health Sciences.
- Pillitteri, A. (2018). Maternal & child health nursing: Care of the childbearing & childrearing family. Lippincott Williams & Wilkins.
- Davidson, M. R., London, M. L., & Ladewig, P. A. (2019). Maternal-newborn nursing: The critical components of nursing care. FA Davis.