Immediate Newborn Care
The first minutes of life — three interventions are given to EVERY newborn.
Priority Actions at Birth
Three Universal Prophylactic Medications
- Vitamin K (phytonadione)
- Prevents hemorrhagic disease of the newborn. Newborns lack clotting factors (sterile gut, can't produce Vit K). IM injection in vastus lateralis within 1 hour of birth. 0.5–1 mg.
- Erythromycin eye ointment
- Prevents ophthalmia neonatorum (gonococcal/chlamydial conjunctivitis from birth canal). Applied to both eyes within 1 hour of birth. Thin ribbon in lower conjunctival sac. May cause temporary blurred vision — do NOT wipe off.
- Hepatitis B vaccine
- First dose of HepB series. Prevents vertical transmission. IM injection within 24 hours of birth.
If a question asks "which medication is given to prevent bleeding in the newborn?" → Vitamin K. If it asks "which prevents eye infection?" → erythromycin. These are two of the most commonly tested newborn medication questions. Both are given to ALL newborns regardless of delivery method.
Every key point in this guide fits on one free printable page. Jump to the free cheatsheet PDF →
APGAR Scoring
Assessed at 1 minute (need for immediate intervention) and 5 minutes (response to interventions).
- A — Appearance (color)0–2 pts
- 0: Blue/pale all over · 1: Body pink, extremities blue (acrocyanosis) · 2: Completely pink
- P — Pulse (heart rate)0–2 pts
- 0: Absent · 1: <100 bpm · 2: ≥100 bpm
- G — Grimace (reflex)0–2 pts
- 0: No response · 1: Grimace/weak cry · 2: Vigorous cry, cough, sneeze
- A — Activity (tone)0–2 pts
- 0: Limp/flaccid · 1: Some flexion · 2: Active motion, well-flexed
- R — Respiration0–2 pts
- 0: Absent · 1: Slow/irregular, weak cry · 2: Strong cry, regular breathing
Interpreting APGAR Scores
- 7–10: Normal — routine care, skin-to-skin
- 4–6: Moderate distress — stimulation, oxygen, possible PPV
- 0–3: Severe distress — immediate resuscitation (PPV, chest compressions, possible intubation)
Blue hands and feet (acrocyanosis) in the first 24–48 hours is NORMAL in newborns and scores a 1 for Appearance (not 0). A score of 1 for color is the most common reason a healthy newborn doesn't score a perfect 10. Central cyanosis (blue trunk/lips) is NOT normal and requires intervention.
? A newborn at 1 minute has body pink/blue extremities, HR 104, grimace, some flexion, and slow irregular respirations — what is the APGAR?
Newborn Assessment
Normal vital signs, measurements, and physical findings.
Normal Newborn Vital Signs
- Heart rate110–160 bpm
- Count for a full minute. Apical pulse. May be higher when crying, lower during sleep.
- Respiratory rate30–60 breaths/min
- Count for a full minute. Periodic breathing (pauses <20 sec) is normal. Apnea >20 sec is NOT normal.
- Temperature97.7–99.5°F axillary
- Axillary method (NOT rectal — risk of perforation). Hypothermia is the greatest risk.
- Weight5.5–8.8 lbs (2,500–4,000 g)
- Normal loss: 5–7% in first 3–5 days. Regain birth weight by day 10–14.
- Length18–22 inches (45–55 cm)
- Head-to-heel measurement.
- Head circumference33–35 cm
- Should be 2 cm larger than chest circumference. Larger → hydrocephalus. Smaller → microcephaly.
Key Physical Findings
- Fontanels: Anterior (diamond-shaped) closes by 12–18 months. Posterior (triangular) closes by 2–3 months. Bulging = increased ICP. Sunken = dehydration.
- Caput succedaneum: Soft tissue swelling that CROSSES suture lines. Resolves in days. From pressure during delivery.
- Cephalohematoma: Blood collection that does NOT cross suture lines (trapped under periosteum of one bone). Resolves in weeks to months. May cause jaundice as blood reabsorbs.
- Milia: Small white bumps on nose/chin — plugged sebaceous glands. Normal, resolves spontaneously. Do NOT squeeze.
- Mongolian spots: Blue-gray patches on buttocks/lower back — normal pigmentation in darker-skinned infants. NOT bruises. Document to prevent confusion with abuse.
- Epstein pearls: Small white cysts on gums or palate — normal. Resolve spontaneously.
- Umbilical cord: 2 arteries + 1 vein. Clamp in place. Keep clean and dry. Falls off in 10–14 days. No tub baths until cord falls off. Report: redness, drainage, foul odor.
Caput succedaneum CROSSES suture lines (soft, diffuse, resolves quickly). Cephalohematoma does NOT cross suture lines (firm, localized to one bone, resolves slowly). This is one of the most commonly tested newborn assessment questions. Remember: Caput = Crosses.
Thermoregulation
Newborns lose heat rapidly — hypothermia is the greatest environmental risk.
Four Types of Heat Loss
- Evaporation
- Wet skin → heat lost as moisture evaporates. Prevention: dry immediately after birth, dry hair, remove wet linens.
- Conduction
- Direct contact with cold surface. Prevention: warm blankets, warm scale before weighing, warm hands before touching baby.
- Convection
- Air currents passing over skin. Prevention: avoid drafts, keep windows closed, no fans near baby, hat on head.
- Radiation
- Body heat radiates to nearby cold objects (not touching). Prevention: keep away from cold walls/windows, use radiant warmer, double-wall isolettes for preemies.
Why Hypothermia is Dangerous
Cold stress → increased metabolic rate → increased oxygen consumption → hypoglycemia → metabolic acidosis → respiratory distress → death. Newborns cannot shiver — they use brown fat (non-shivering thermogenesis) which is a limited supply.
Never take a rectal temperature on a newborn — risk of rectal perforation. Use axillary method. Normal: 97.7–99.5°F. If the temp is low → skin-to-skin (kangaroo care) is the most effective warming method. Do NOT use a heating pad (burns).
Neonatal Hypoglycemia
Blood glucose <40 mg/dL in the newborn — screen high-risk infants.
High-Risk Infants
- Infant of diabetic mother (IDM) — most common at-risk group
- Large for gestational age (LGA) or small for gestational age (SGA)
- Preterm infants
- Cold-stressed infants
Signs of Hypoglycemia
- Jitteriness, tremors
- Poor feeding, weak suck
- Lethargy, hypotonia
- Tachypnea, apnea
- Cyanosis
- Seizures (severe)
Nursing Interventions
- Feed early — breastfeed or formula within 1 hour of birth for at-risk infants
- Check blood glucose per protocol (heel stick at 1 hour, before feeds)
- If symptomatic or glucose <25 mg/dL → IV dextrose (D10W)
- If asymptomatic and glucose 25–40 mg/dL → feed and recheck in 30–60 min
Jaundice & Phototherapy
Yellow skin from bilirubin buildup — know physiologic vs pathologic.
- Onset
- Physiologic: After 24 hours of life. Pathologic: Within first 24 hours.
- Cause
- Physiologic: Normal RBC breakdown + immature liver. Pathologic: Rh/ABO incompatibility, infection, liver disease.
- Peak
- Physiologic: Days 2–4 (term), day 5–7 (preterm). Pathologic: Rises rapidly, may not peak on its own.
- Treatment
- Physiologic: Frequent feeding (promotes stooling → excretes bilirubin). Pathologic: Phototherapy, possible exchange transfusion.
Phototherapy Nursing Care
- Eye protection: Cover eyes with opaque shields (bilirubin lights can damage retinas). Remove during feedings and check for irritation.
- Expose maximum skin — baby wears only diaper. No lotions or creams (can cause burns under lights).
- Monitor temperature — risk of hyperthermia and dehydration under lights
- Increase feedings — promotes stooling which excretes bilirubin. Monitor I&O closely.
- Monitor bilirubin levels — check per protocol to assess effectiveness
- Assess stool color — should become green and loose (bilirubin excreting). Document.
- Reposition frequently — expose different skin surfaces to the light
If a question says the baby is jaundiced within the first 24 hours → this is ALWAYS pathologic and requires immediate investigation (bilirubin level, Coombs test, blood type). Physiologic jaundice never appears before 24 hours. This is one of the most tested newborn questions.
Newborn Reflexes
Primitive reflexes are present at birth and disappear as the CNS matures.
- Moro (startle)disappears 3–6 months
- Elicit: sudden loud noise or head drop. Response: arms extend and abduct, fingers fan out, then arms flex and adduct ("embrace").
- Rootingdisappears 3–4 months
- Elicit: stroke cheek or corner of mouth. Response: turns head toward stimulus, opens mouth.
- Suckingdisappears 10–12 months
- Elicit: place finger or nipple in mouth. Response: rhythmic sucking.
- Palmar graspdisappears 3–4 months
- Elicit: place finger in palm. Response: fingers curl around object tightly.
- Plantar graspdisappears 8–10 months
- Elicit: press thumb on ball of foot. Response: toes curl downward.
- Babinskidisappears 12–24 months
- Elicit: stroke lateral sole from heel to toe. Response: toes fan out and dorsiflex. NORMAL in infants, abnormal in adults.
- Tonic neck (fencing)disappears 3–4 months
- Elicit: turn head to one side while supine. Response: arm and leg extend on the side head faces, opposite side flexes.
- Steppingdisappears 4–8 weeks
- Elicit: hold upright with feet touching surface. Response: makes stepping/walking motions.
A positive Babinski reflex (toes fanning out) is NORMAL in infants up to 12–24 months. In adults, a positive Babinski is abnormal and indicates an upper motor neuron lesion. If a question asks about Babinski in a newborn → normal finding, no intervention needed.
Circumcision Care
Post-procedure care depends on the method used.
Two Methods
- Gomco clamp: Foreskin removed surgically. Apply petroleum jelly gauze to the site with each diaper change for 24–48 hours (prevents sticking to diaper).
- Plastibell: Plastic ring left in place — falls off on its own in 5–8 days. Do NOT pull it off. No petroleum jelly needed. Slight swelling is normal.
Nursing Care
- Monitor for bleeding (most common complication) — small amount normal, active bleeding → apply gentle pressure and notify provider
- Yellowish exudate over the glans is NORMAL (granulation tissue healing — NOT infection). Do NOT remove.
- Clean with warm water only — no soap, alcohol, or wipes on the site
- Loose diaper to avoid pressure on the site
- Report: active bleeding, foul-smelling drainage, inability to urinate within 6–8 hours
Parents often mistake the yellowish crust over a circumcision site for pus/infection. This is normal granulation tissue and should NOT be removed. If a question describes yellow exudate on a circumcision site → the answer is normal finding, no intervention needed.
Metabolic Screening
State-mandated newborn screening — done before discharge.
- Newborn metabolic screening (heel stick blood test) — screens for PKU, hypothyroidism, sickle cell disease, galactosemia, CF, and other metabolic disorders (varies by state)
- Timing: After 24 hours of life (need adequate feeding for accurate PKU results). Ideally before hospital discharge.
- PKU (Phenylketonuria): Cannot metabolize phenylalanine. If untreated → intellectual disability. Treatment: lifelong phenylalanine-restricted diet. Avoid aspartame (NutraSweet).
- Congenital hypothyroidism: If untreated → cretinism (intellectual and growth impairment). Treatment: lifelong levothyroxine (thyroid hormone replacement).
- Hearing screen: Done before discharge. Identifies hearing loss for early intervention.
- Critical congenital heart defect screening: Pulse oximetry on right hand AND one foot. Difference >3% between pre/post-ductal = abnormal → echocardiogram.
Safe Sleep & SIDS Prevention
The ABCs of safe sleep — every parent needs this teaching.
ABCs of Safe Sleep
- Alone — baby sleeps alone (no co-sleeping, no stuffed animals, no pillows, no bumper pads)
- Back — always on the BACK (supine). Never prone or side-lying for sleep.
- Crib — firm, flat mattress in a safety-approved crib. Fitted sheet only. No loose bedding, blankets, or soft objects.
Additional SIDS Risk Reduction
- Room-sharing (baby in same room as parents) but NOT bed-sharing for the first 6–12 months
- Offer a pacifier at sleep (after breastfeeding is established — usually 3–4 weeks)
- No smoking around the infant (secondhand smoke increases SIDS risk)
- Avoid overheating — dress in one layer more than the adult is wearing
- Breastfeeding reduces SIDS risk
- Keep immunizations up to date
- Tummy time when AWAKE and supervised — promotes motor development and prevents flat head (plagiocephaly)
ALWAYS place the baby on their BACK for sleep — this is the single most important SIDS prevention measure. Tummy time is for when the baby is AWAKE and supervised only. If a question describes a baby sleeping on the stomach → the nurse must intervene and reposition to supine.
Frequently Asked Questions
Common student questions on this topic.
What is the APGAR score and what do the numbers mean?
What is the normal newborn vital sign range?
What are the normal newborn reflexes I should assess?
What is the difference between physiologic and pathologic jaundice?
What newborn screenings are required by law?
What are the signs that a newborn is feeding well?
Quick-Reference Cheatsheet
Every key point from this guide on a single printable page.
Newborn Care Cheatsheet
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