Neonatal Care for the NCLEX

Transition at Birth and Immediate Care

At birth the newborn must aerate the lungs, switch from fetal to neonatal circulation, and begin generating its own heat and glucose. Nursing priority in the first minutes follows airway, breathing, circulation, with warmth as an immediate parallel concern because cold stress rapidly drives hypoglycaemia and respiratory distress.

• First actions: dry the infant thoroughly, remove wet linen, provide warmth (skin to skin or radiant warmer), position to open the airway, and stimulate. Suction the mouth before the nose so the infant does not gasp and aspirate.
• Fetal circulation shunts close after birth: the foramen ovale closes functionally as left atrial pressure rises, the ductus arteriosus constricts as oxygen tension rises and prostaglandins fall (usually within 24 to 72 hours), and the ductus venosus closes with cord clamping.
• The first period of reactivity lasts about 30 minutes after birth and is the ideal window for breastfeeding initiation and bonding; a sleep phase follows, then a second period of reactivity at about 2 to 8 hours when gagging and mucus are common.
• Routine prophylaxis: erythromycin ophthalmic ointment within about one hour to prevent gonococcal and chlamydial ophthalmia neonatorum, and a single intramuscular dose of vitamin K (phytonadione) in the vastus lateralis to prevent vitamin K deficiency bleeding, because the newborn gut is sterile and cannot synthesise it.
• Cord care is dry care: keep it clean and dry, fold the diaper below it, and report redness, foul odour or purulent drainage. It usually separates in 7 to 14 days.

Apgar Score, Vital Signs and Normal Values

The Apgar score is assigned at 1 and 5 minutes and repeated every 5 minutes up to 20 minutes if the score stays below 7. It describes the need for resuscitation; it is not used to predict long-term outcome and it never delays resuscitation, which begins on assessment alone.

• Five Apgar parameters, each scored 0, 1 or 2: heart rate, respiratory effort, muscle tone, reflex irritability, and colour. Maximum score is 10.
• Interpretation: 7 to 10 no distress, 4 to 6 moderate distress requiring support, 0 to 3 severe distress requiring active resuscitation. Heart rate is the most important single sign.
• Normal heart rate 110 to 160 beats per minute (may drop to about 90 in deep sleep and rise to 180 when crying), apical for one full minute.
• Normal respiratory rate 30 to 60 breaths per minute, irregular, mainly diaphragmatic, counted for one full minute. Periodic breathing with pauses under 20 seconds is normal; apnoea over 20 seconds is not.
• Normal axillary temperature 36.5 to 37.5 degrees Celsius. Axillary is preferred; rectal temperature is avoided because of perforation risk.
• Normal measurements: weight 2500 to 4000 grams, length 45 to 55 centimetres, head circumference 33 to 35 centimetres, chest circumference 30 to 33 centimetres. Head circumference is normally about 2 to 3 centimetres larger than chest.
• Blood glucose should be above 40 to 45 milligrams per decilitre; heel stick is the correct site, using the lateral aspect of the heel.
• Expected reflexes: Moro, rooting, sucking, palmar and plantar grasp, Babinski (positive fanning is normal until about 1 year), stepping, tonic neck. Absent or asymmetric Moro suggests injury such as a fractured clavicle or brachial plexus palsy.

Thermoregulation, Feeding and Elimination

Newborns lose heat rapidly through a large surface area, thin subcutaneous fat and an inability to shiver. They generate heat by non-shivering thermogenesis, metabolising brown adipose tissue. Cold stress consumes glucose and oxygen and produces a predictable chain of hypoglycaemia, respiratory distress and metabolic acidosis, so preventing heat loss is a nursing priority, not a comfort measure.

• Four routes of heat loss: convection (drafts), conduction (cold surfaces such as a scale), radiation (cold walls or windows nearby) and evaporation (wet skin). Match each route to the correct intervention in exam questions.
• Breastfeeding: 8 to 12 feeds in 24 hours on demand. Signs of adequate intake are audible swallowing, contented sleep after feeds, and appropriate output.
• Formula feeding: about every 3 to 4 hours. Never prop the bottle, never microwave formula, and discard formula left in the bottle.
• Expected output by day 4: at least 6 to 8 wet diapers per day, and 3 or more stools per day in the breastfed newborn.
• Stool sequence: meconium (sticky, black-green) within 24 to 48 hours, then transitional greenish-brown, then milk stools. Breastfed stools are yellow, seedy and loose; formula stools are paler and firmer.
• Weight: up to 10 percent loss in the first week is physiological, with birth weight regained by 10 to 14 days.
• Do not give water, honey (risk of infant botulism) or cow's milk in the first year. Vitamin D supplementation is recommended for the breastfed infant.

Jaundice, Respiratory and Metabolic Problems

Distinguishing physiological from pathological jaundice is one of the most frequently tested judgements in newborn care. The key discriminator is timing: jaundice appearing in the first 24 hours of life is always pathological and requires immediate reporting.

• Physiological jaundice appears after 24 hours, peaks at day 3 to 5 in the term infant, and resolves within about a week. It reflects immature hepatic conjugation and a high red cell turnover.
• Pathological jaundice appears within the first 24 hours, rises rapidly, or persists beyond 2 weeks; common causes are ABO or Rh incompatibility, sepsis and haemolysis.
• Untreated severe unconjugated hyperbilirubinaemia can cause kernicterus (bilirubin encephalopathy): lethargy, poor feeding, high-pitched cry, hypotonia then hypertonia and opisthotonos.
• Phototherapy nursing care: maximise skin exposure, apply eye shields, monitor temperature and hydration, encourage frequent feeding, and expect loose green stools. Do not apply lotions or oils to the skin.
• Respiratory distress signs to report: nasal flaring, grunting, intercostal or subcostal retractions, tachypnoea over 60, central cyanosis, and see-saw breathing. Acrocyanosis (blue hands and feet) is normal in the first 24 to 48 hours; central cyanosis is not.
• Newborns are obligate nose breathers, so nasal obstruction can itself cause distress; choanal atresia presents with cyanosis relieved by crying.
• Hypoglycaemia risk groups: infants of diabetic mothers, preterm, small or large for gestational age, and cold-stressed infants. Signs are jitteriness, poor feeding, lethargy, temperature instability and a weak high-pitched cry.
• Infants of diabetic mothers are macrosomic and at risk of hypoglycaemia after birth because their own high insulin output continues once the maternal glucose supply is cut off.

Infection, Screening and Parent Teaching

Newborn sepsis rarely presents with fever. The classic exam trap is that the septic newborn is more likely to be hypothermic, lethargic and feeding poorly, so any subtle change in tone, temperature or feeding must be treated as significant.

• Early signs of neonatal sepsis: temperature instability (often low), poor feeding, lethargy, hypotonia, apnoea, jaundice and subtle behaviour change. Group B streptococcus is a leading cause of early-onset sepsis.
• Neonatal abstinence syndrome presents with high-pitched cry, irritability, tremors, poor feeding, sneezing, diarrhoea and excoriation. Care includes swaddling, a quiet dim environment, small frequent feeds and minimal handling.
• Routine screening before discharge: metabolic newborn screen (heel stick, best after 24 hours of feeding), hearing screen, and pulse oximetry screening for critical congenital heart disease.
• Hepatitis B vaccine is given within 24 hours of birth; if the mother is hepatitis B surface antigen positive, hepatitis B immune globulin is given as well.
• Safe sleep teaching: supine position, firm flat surface, no pillows, bumpers, loose blankets or soft toys, room sharing without bed sharing, and no smoking exposure.
• Normal newborn findings that alarm parents but need only reassurance: milia, Mongolian spots (congenital dermal melanocytosis), erythema toxicum, vernix caseosa, lanugo, pseudomenstruation, swollen breasts from maternal hormones, caput succedaneum (crosses suture lines, resolves in days) and cephalhaematoma (does not cross suture lines, resolves in weeks and raises jaundice risk).
• Always report: bulging or sunken fontanelle, seizures, no void in 24 hours, no stool in 48 hours, jaundice in the first 24 hours, temperature instability, and any central cyanosis.

Key Terms

Non-shivering thermogenesis

Heat production by metabolism of brown adipose tissue; the newborn's main defence against cold because it cannot shiver.

Acrocyanosis

Bluish discolouration of the hands and feet from sluggish peripheral circulation; a normal finding in the first 24 to 48 hours, unlike central cyanosis.

Kernicterus

Irreversible brain injury caused by deposition of unconjugated bilirubin in the basal ganglia, the reason severe neonatal jaundice is treated urgently.

Cephalhaematoma

A collection of blood between the skull bone and periosteum that does not cross suture lines, resolves over weeks and increases the risk of jaundice.

Practice Quiz — 20 Questions

1. A newborn has a heart rate of 130, a strong cry, active motion, a vigorous cough on suctioning, and a pink body with blue extremities. The Apgar score is:

   • A.7
   • B.8
   • C.9
   • D.10
   C. 9 — Four parameters score 2 each and colour scores 1 because of acrocyanosis, giving a total of 9.

2. The nurse's first action after delivery of a term newborn is to:

   • A.Give vitamin K
   • B.Dry the infant and provide warmth
   • C.Apply the identification band
   • D.Obtain a heel stick glucose
   B. Dry the infant and provide warmth — Drying and warming prevents evaporative heat loss and cold stress, and is done with airway positioning as the immediate priority.

3. Which normal newborn respiratory rate is expected?

   • A.16 to 20 per minute
   • B.20 to 30 per minute
   • C.30 to 60 per minute
   • D.60 to 80 per minute
   C. 30 to 60 per minute — A term newborn breathes 30 to 60 times per minute; a sustained rate above 60 suggests distress.

4. Vitamin K is given to the newborn because:

   • A.The mother's supply is depleted
   • B.The newborn gut is sterile and cannot synthesise it
   • C.It prevents jaundice
   • D.It stimulates surfactant production
   B. The newborn gut is sterile and cannot synthesise it — Vitamin K is normally made by intestinal flora, which the newborn does not yet have, so clotting factor synthesis is impaired.

5. Jaundice noted at 12 hours of age should be interpreted as:

   • A.Normal physiological jaundice
   • B.Pathological and reported immediately
   • C.A sign of good hepatic function
   • D.Expected in breastfed infants
   B. Pathological and reported immediately — Jaundice within the first 24 hours is always pathological and suggests haemolysis, incompatibility or sepsis.

6. A newborn placed on a cold metal scale loses heat primarily by:

   • A.Convection
   • B.Conduction
   • C.Radiation
   • D.Evaporation
   B. Conduction — Conduction is direct heat transfer to a cooler surface in contact with the skin.

7. Which finding in a 2-day-old newborn requires immediate reporting?

   • A.Acrocyanosis
   • B.Grunting with nasal flaring
   • C.Milia on the nose
   • D.A weight loss of 5 percent
   B. Grunting with nasal flaring — Grunting and flaring are signs of respiratory distress; the other three findings are normal.

8. Newborn heel stick blood glucose should be maintained above approximately:

   • A.20 milligrams per decilitre
   • B.40 milligrams per decilitre
   • C.70 milligrams per decilitre
   • D.100 milligrams per decilitre
   B. 40 milligrams per decilitre — A value below about 40 to 45 milligrams per decilitre is treated as hypoglycaemia in the newborn.

9. An infant of a diabetic mother is at greatest risk in the first hours of life for:

   • A.Hyperglycaemia
   • B.Hypoglycaemia
   • C.Hypernatraemia
   • D.Polycythaemia only
   B. Hypoglycaemia — Fetal hyperinsulinaemia persists after the maternal glucose supply stops at cord clamping, dropping the blood glucose sharply.

10. A soft swelling on the newborn's head that crosses the suture lines is:

    • A.Cephalhaematoma
    • B.Caput succedaneum
    • C.Subgaleal haemorrhage
    • D.Craniosynostosis
    B. Caput succedaneum — Caput succedaneum is oedema of the scalp that crosses sutures and resolves within a few days; a cephalhaematoma does not cross sutures.

11. During phototherapy the nurse should:

    • A.Apply lotion to protect the skin
    • B.Cover the eyes and maximise skin exposure
    • C.Restrict feedings to reduce stool output
    • D.Keep the infant fully clothed
    B. Cover the eyes and maximise skin exposure — Eye shields prevent retinal damage and maximal skin exposure improves bilirubin breakdown; feeds are increased, not restricted, to promote excretion.

12. By the fourth day of life, the expected number of wet diapers per 24 hours is at least:

    • A.2
    • B.4
    • C.6
    • D.12
    C. 6 — Six to eight wet diapers a day indicates adequate intake once the milk supply is established.

13. Which weight change is within normal limits for a term newborn in the first week?

    • A.Loss of up to 10 percent of birth weight
    • B.Loss of up to 25 percent of birth weight
    • C.Gain of 10 percent in 3 days
    • D.No change at all
    A. Loss of up to 10 percent of birth weight — Physiological weight loss of up to 10 percent occurs in the first days, with birth weight regained by 10 to 14 days.

14. The first stool passed by a newborn is called:

    • A.Transitional stool
    • B.Meconium
    • C.Milk stool
    • D.Steatorrhoea
    B. Meconium — Meconium is thick, sticky and black-green and should be passed within 24 to 48 hours of birth.

15. Erythromycin ophthalmic ointment is given to the newborn to prevent:

    • A.Retinopathy of prematurity
    • B.Ophthalmia neonatorum
    • C.Cataracts
    • D.Strabismus
    B. Ophthalmia neonatorum — It prevents gonococcal and chlamydial conjunctivitis acquired during passage through the birth canal.

16. A hallmark early sign of sepsis in a newborn is:

    • A.High fever
    • B.Temperature instability with poor feeding
    • C.Bounding pulses
    • D.Increased appetite
    B. Temperature instability with poor feeding — Newborns often become hypothermic rather than febrile, and subtle lethargy or poor feeding may be the only clue.

17. An absent Moro reflex on one side most likely indicates:

    • A.Normal variation
    • B.Clavicular fracture or brachial plexus injury
    • C.Hypoglycaemia
    • D.Physiological jaundice
    B. Clavicular fracture or brachial plexus injury — Asymmetry of the Moro reflex suggests birth trauma to the clavicle or the brachial plexus on that side.

18. Parents of a newborn should be taught to place the infant to sleep:

    • A.Prone on a soft mattress
    • B.Side-lying with a rolled blanket
    • C.Supine on a firm flat surface
    • D.Prone with a pillow under the chest
    C. Supine on a firm flat surface — Supine positioning on a firm surface with no soft bedding reduces the risk of sudden infant death syndrome.

19. Which food must be avoided in the first year of life because of the risk of infant botulism?

    • A.Honey
    • B.Rice cereal
    • C.Mashed banana
    • D.Iron-fortified formula
    A. Honey — Honey may contain Clostridium botulinum spores that the immature infant gut cannot handle.

20. The newborn metabolic screening heel stick is best obtained:

    • A.Immediately after birth
    • B.After at least 24 hours of feeding
    • C.At the first well-child visit only
    • D.Only if the infant is symptomatic
    B. After at least 24 hours of feeding — The infant must have taken feeds for about 24 hours so that metabolites such as phenylalanine can accumulate and be detected.

References

• American Academy of Pediatrics, Newborn care and safe sleep recommendations — https://www.aap.org/
• World Health Organization, Newborn health guidelines — https://www.who.int/health-topics/newborn-health
• Centers for Disease Control and Prevention, Newborn screening — https://www.cdc.gov/newborn-screening/
• StatPearls, Neonatal Jaundice — https://www.ncbi.nlm.nih.gov/books/NBK532930/
• NCSBN NCLEX-RN Test Plan, Health Promotion and Maintenance and Physiological Adaptation — https://www.ncsbn.org/exams/testplans.page