8.2 Neonatal Assessment, APGAR Scoring & Newborn Nursing Care
Key Takeaways
Initial newborn care is drying, warming and stimulating; ventilation starts within the first minute if the baby is not breathing or the heart rate is below 100/min.
Apgar scores at 1 and 5 minutes rate Appearance, Pulse, Grimace, Activity and Respiration; resuscitation decisions rest on breathing and heart rate, not on the score.
Caput succedaneum is benign subcutaneous serosanguinous edema crossing cranial suture lines, whereas cephalohematoma is subperiosteal hemorrhage confined within suture boundaries that increases neonatal hyperbilirubinemia risk.
Standard universal prophylactic interventions include intramuscular Vitamin K (phytonadione) into the vastus lateralis to prevent hemorrhagic disease of the newborn and topical erythromycin 0.5% ophthalmic ointment to prevent gonococcal ophthalmia neonatorum.
Physiological jaundice appears benignly after 24 hours of life due to normal RBC breakdown and immature hepatic glucuronyl transferase, whereas pathological jaundice presents within the first 24 hours and necessitates immediate investigation for hemolytic disease (Rh/ABO incompatibility).
Neonatal Assessment, APGAR Scoring & Newborn Nursing Care
Clinical Overview: The transition from fetal to extrauterine life is the most vulnerable physiological adaptation in human development. Registered nurses must execute delivery room stabilization, establish precise clinical scoring using the APGAR system, perform comprehensive head-to-toe physical assessments, and implement evidence-based prophylactic care. Identifying acute transitional emergencies—such as respiratory depression, cold stress, severe hypoglycemia, and pathological hyperbilirubinemia—is vital for preventing neonatal morbidity on the RENR.
Immediate Delivery Room Care & APGAR Scoring
At delivery, immediate nursing care centers on establishing respiration and thermal stability:
- Airway Clearance: Routine suctioning is not recommended. Suction only if secretions obstruct the airway, and then do the mouth first, then the nose, because suctioning the nose first can trigger gasping and aspiration.
- Thermoregulation & Stimulation: Dry infant thoroughly, discard wet linens, and place infant skin-to-skin or under a radiant warmer. Hypothermia induces cold stress, leading to hypoxia, pulmonary vasoconstriction, metabolic acidosis, and rapid glucose depletion.
The APGAR Scoring System
Calculated at 1 minute and 5 minutes following birth (repeated every 5 minutes up to 20 minutes if score <7):
| Parameter | Score = 0 | Score = 1 | Score = 2 |
|---|---|---|---|
| A — Appearance (Color) | Pale or blue | Pink body, blue extremities (Acrocyanosis) | Completely pink |
| P — Pulse (Heart Rate) | Absent | <100 beats/minute | >=100 beats/minute |
| G — Grimace (Reflex irritability) | No response | Grimace | Cry, cough, sneeze or pulls away |
| A — Activity (Tone) | Limp | Some extremity flexion | Active motion, well-flexed |
| R — Respiration (Effort) | Absent | Slow, irregular, weak | Vigorous lusty cry |
Score Interpretation & Resuscitation Decisions
The Apgar score describes the baby's condition and response to resuscitation. It is not used to decide whether to start resuscitation, which begins before the 1-minute score is known. Use the newborn resuscitation algorithm instead:
- Dry, warm and stimulate the baby, and position the airway.
- If the baby is not breathing, is gasping, or the heart rate is below 100/min, start positive-pressure ventilation (40–60 breaths/min) within the first minute (the "golden minute").
- If the heart rate stays below 60/min after 30 seconds of effective ventilation, start chest compressions at a 3:1 ratio and prepare epinephrine.
As a rough guide, Apgar scores of 7–10 are reassuring, 4–6 moderately abnormal and 0–3 low.
Comprehensive Neonatal Physical Examination
- Heart Rate: 110–160 beats/min (apical pulse counted for a full minute).
- Respiratory Rate: 30–60 breaths/min (counted for full minute; diaphragmatic; pauses <15 seconds are normal periodic breathing).
- Axillary Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F). Avoid rectal readings to prevent mucosal perforation.
- Measurements: Head: 33–35 cm; Chest: 30–33 cm; Weight: 2,500–4,000 g (5–10% weight loss in first 3–5 days, regained by 10–14 days).
Cranial Assessment: Fontanelles & Birth Trauma
- Anterior Fontanelle: Diamond-shaped, 2–4 cm; soft and flat; closes at 12 to 18 months.
- Posterior Fontanelle: Triangular, 0.5–1 cm; closes at 6 to 8 weeks (2 months). Bulging at rest indicates increased intracranial pressure; sunken indicates dehydration.
| Characteristic | Caput Succedaneum | Cephalohematoma |
|---|---|---|
| Tissue Layer | Subcutaneous edema above periosteum | Subperiosteal hemorrhage below periosteum |
| Suture Lines | Crosses cranial suture lines | Does NOT cross suture lines (confined to bone) |
| Onset & Course | Present at birth; resolves in 3 to 4 days | Appears hours after birth; resolves in 2 to 8 weeks |
| Clinical Risk | Benign; no significant sequelae | High risk of hyperbilirubinemia from RBC lysis |
Primitive Neonatal Reflexes
- Moro (Startle): Symmetrical arm abduction/extension with fingers in 'C', followed by flexion. Fades by 4–6 months. Asymmetry indicates clavicular fracture or Erb's palsy.
- Rooting & Sucking: Cheek stroke causes turning toward touch; rhythmic sucking follows. Fades by 4 months.
- Palmar & Plantar Grasp: Pressure in palm or sole triggers tight flexion. Palmar fades by 3–4 months; plantar by 8–9 months.
- Babinski Reflex: Lateral sole stroke upward produces dorsiflexion of great toe and fanning of other toes. Normal up to 12–24 months.
- Tonic Neck ('Fencing'): Turning head causes ipsilateral arm/leg extension and contralateral flexion. Fades by 5–7 months.
Essential Prophylactic Newborn Interventions
- Vitamin K (Phytonadione): 0.5 to 1.0 mg IM in vastus lateralis via 25-gauge, 5/8-inch needle at 90 degrees. Because the neonatal gut is sterile at birth and lacks bacteria to synthesize vitamin K, deficiency of clotting factors II, VII, IX, and X exists. Prevents hemorrhagic disease of the newborn.
- Erythromycin Ophthalmic Ointment (0.5%): Applied into each lower conjunctival sac within 1 hour of birth. Prevents ophthalmia neonatorum from maternal Neisseria gonorrhoeae (which causes blindness) and Chlamydia trachomatis.
- Hepatitis B Vaccine: WHO recommends a birth dose within 24 hours. Jamaica's routine public schedule gives BCG at birth and starts hepatitis B with the pentavalent vaccine at 6 weeks (Section 3.1), so follow the national and facility protocol. A baby born to an HBsAg-positive mother needs hepatitis B vaccine plus hepatitis B immune globulin (HBIG) within 12 hours of birth, at separate sites.
Neonatal Hypoglycemia & Hyperbilirubinemia
Hypoglycemia Surveillance
Defined as blood glucose <40 mg/dL (2.2 mmol/L) in first 24 hours. High-risk infants include infants of diabetic mothers, SGA, preterm, and cold-stressed infants.
- Clinical Signs: Jitteriness/tremors (stops when limb is held, unlike seizures), weak/high-pitched cry, hypotonia, lethargy, hypothermia, tachypnea, and apnea.
- Nursing Actions: Obtain heel stick on lateral/medial plantar borders. If <40 mg/dL, feed immediately with breast milk or formula. Recheck glucose in 30–60 minutes. If refractory, administer IV 10% dextrose (D10W).
Hyperbilirubinemia: Physiologic vs. Pathologic
- Physiologic Jaundice: Appears AFTER 24 hours of life (days 2–4). Benign; caused by accelerated fetal RBC breakdown and immature hepatic glucuronyl transferase. Resolves in 7–10 days.
- Pathologic Jaundice: Appears WITHIN first 24 hours of life. Caused by hemolysis (Rh/ABO incompatibility, G6PD deficiency, sepsis). Bilirubin rises rapidly (>5 mg/dL/day), carrying high risk of kernicterus (toxic bilirubin encephalopathy; causes choreoathetosis, deafness, death).
- Phototherapy Care: Photoisomerizes bilirubin into water-soluble lumirubin. Apply opaque eye shields over closed eyes. Undress infant down to minimal diaper. Do not apply lotions. Maintain axillary temperature 36.5°C–37.5°C and ensure frequent feedings every 2–3 hours. Turn infant every 2 hours. Turn off phototherapy during blood draws.
At 1 minute after birth, a registered nurse assesses a full-term newborn. The infant has an apical heart rate of 118 beats/minute, a vigorous lusty cry, actively flexed extremities, coughs promptly when suctioned with a catheter, and has a pink trunk with cyanotic hands and feet. What is the calculated 1-minute APGAR score?
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A registered nurse prepares to administer routine prophylactic medications to a healthy full-term infant 1 hour following birth. Which anatomical site and injection technique must the nurse utilize for the phytonadione (Vitamin K) injection?
Dorsogluteal muscle using a 22-gauge, 1-inch needle inserted at a 45-degree angle
Anterolateral thigh (vastus lateralis), 25-gauge 5/8-inch needle at 90 degrees
Subcutaneous abdominal tissue using a 25-gauge needle inserted at a 45-degree angle
Deltoid muscle using a 27-gauge, 1/2-inch needle inserted at a 15-degree angle
A full-term infant born 14 hours ago is noted by the registered nurse to have noticeable yellowish discoloration of the sclera, face, and upper thorax. How should the nurse clinically interpret and act on this finding?
Reassure the mother that this represents benign breast milk jaundice requiring no intervention
Recognize this as harmless carotenemia resulting from maternal prenatal dietary intake
Identify this as pathological jaundice requiring immediate physician notification and hemolytic workup
Recognize this as expected physiological jaundice and document the finding as normal
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