Normal Newborn Assessment & Care - Cheat Sheet
Your 30-minute rapid-fire reference for newborn APGAR scoring, vital signs, reflexes, immediate care (EINC/Unang Yakap), thermoregulation, prophylactic meds, and RA 9288 newborn screening. Every item here is testable.
APGAR Score — The Foundation
Formulas
APGAR Total = A + P + G + A + R (each 0, 1, or 2)
Meaning
A = Appearance (color), P = Pulse (heart rate), G = Grimace (reflex), A = Activity (muscle tone), R = Respiration
Watch out
Acrocyanosis (blue hands/feet) = 1 point, NOT 0. Do NOT delay resuscitation waiting for 1-min score — resuscitation is based on HR and breathing, not APGAR timing.
When to use
At 1 minute and 5 minutes after birth; repeat every 5 min up to 20 min if score <7
Common values
Value
>100 beats/min
Symbol
HR
Quantity
Heart rate for APGAR = 2
Value
<100 beats/min
Symbol
HR
Quantity
Heart rate for APGAR = 1
Value
1 min and 5 min after birth
Symbol
t
Quantity
APGAR scoring timing
Important facts
- APGAR is scored at 1 min and 5 min; repeat every 5 min if <7 (up to 20 min)
- Resuscitation is guided by heart rate and breathing, NOT by APGAR score — do not wait for 1-min score
- Acrocyanosis is NORMAL in first 24 hours and does not indicate hypoxia
- Asymmetric Moro or weak cry at 1 min may indicate birth trauma; investigate
- In extremely preterm infants, APGAR may be low but prognosis depends on resuscitation response
Key definitions
APGAR Score 7–10
Example
Completely pink, HR 120, strong cry, well flexed, vigorous breathing
Good adaptation; routine care only.
APGAR Score 4–6
Example
Body pink/extremities blue, HR 90, weak cry, some flexion, slow irregular breathing
Moderately depressed; may need stimulation, oxygen, or airway support.
APGAR Score 0–3
Example
Blue/pale all over, no pulse, no response, limp, no respiratory effort
Severely depressed; active resuscitation required immediately.
Acrocyanosis
Example
Baby's trunk is pink but fingers/toes are blue — normal, costs 1 point on APGAR, not a sign of hypoxia
Normal blue discoloration of hands and feet in first 24 hours; result of sluggish peripheral perfusion.
Diagrams to know
- APGAR scoring table (5 parameters × 3 point values)
- APGAR interpretation flowchart (score → action pathway)
Normal Vital Signs & Measurements
Common values
Value
110–160 bpm
Symbol
HR
Quantity
Newborn HR (resting)
Value
30–60 breaths/min
Symbol
RR
Quantity
Newborn RR
Value
36.5–37.5°C
Symbol
T
Quantity
Axillary temperature
Value
2,500–4,000 g
Symbol
Wt
Quantity
Normal weight
Value
45–55 cm
Symbol
L
Quantity
Normal length
Value
33–35 cm (2–3 cm > chest)
Symbol
HC
Quantity
Head circumference
Value
>45 mg/dL
Symbol
BG
Quantity
Blood glucose minimum
Important facts
- Count apical HR for a FULL minute (newborn HR is irregular)
- RR may be irregular with brief pauses (periodic breathing) — normal
- Axillary temperature is the gold standard; rectal is contraindicated
- Normal weight loss = 5–10%; excessive loss (>15%) suggests poor feeding or dehydration
- Head circumference should be 2–3 cm LARGER than chest circumference
- Chest circumference = 30–33 cm; head = 33–35 cm
- Length = 45–55 cm (average 50 cm)
- Blood glucose must stay >45 mg/dL; <40–45 is hypoglycemia (jittery, poor feeding, lethargy)
Key definitions
Heart Rate (Apical)
Example
Sleeping newborn: 100 bpm; crying newborn: 160 bpm — both normal
110–160 beats/min (up to ~180 when crying, ~100 when sleeping); count for full 60 seconds.
Respiratory Rate
Example
Newborn takes 8 breaths, pauses 10 sec, resumes — normal periodic breathing
30–60 breaths/min, irregular and abdominal; brief periodic breathing pauses <15–20 sec are normal.
Axillary Temperature
Example
Temp 37.2°C axillary = normal; 36.0°C = mild hypothermia, action needed
36.5–37.5°C (97.7–99.5°F); preferred site in newborns (avoid rectal due to perforation risk).
Blood Pressure
Example
Not a routine vital sign in well babies; take only if clinical concern
Approximately 60–80 / 40–50 mmHg; not routinely measured in healthy newborns.
Weight Loss
Example
3,400 g at birth; 3,150 g at day 2 (7% loss) = normal; >15% warrants investigation
5–10% loss in first 3–5 days is physiologic (from fluid loss, meconium); regained by 10–14 days.
Diagrams to know
- Normal vital signs quick-reference table
- Weight loss curve (% loss per day 1–14)
Newborn Reflexes — Recognize Normal & Abnormal
Common values
Value
3–4 months
Symbol
Age
Quantity
Rooting disappearance
Value
10–12 months
Symbol
Age
Quantity
Sucking disappearance
Value
6 months
Symbol
Age
Quantity
Moro disappearance
Value
4 months
Symbol
Age
Quantity
Tonic neck disappearance
Important facts
- ASYMMETRIC Moro = RED FLAG: fractured clavicle, brachial plexus (Erb) palsy, or birth trauma
- Babinski (toe fanning) is NORMAL in infants; becomes abnormal in adults (indicates CNS lesion)
- Absence of any reflex + other signs = neurologic concern; report
- Weak or exaggerated reflexes may indicate prematurity, medications, or CNS insult
- Disappearance of reflexes on schedule is NORMAL; persistence may indicate developmental delay
- All primitive reflexes should be symmetric (except expected asymmetry in paralysis)
Key definitions
Rooting Reflex
Example
Brush infant's cheek, baby turns head toward your finger
Stroke cheek → head turns toward stimulus; aids feeding. Disappears 3–4 months.
Sucking Reflex
Example
Place finger in baby's mouth, automatic suck occurs
Object in mouth → infant sucks; essential for feeding. Fades 10–12 months.
Palmar Grasp
Example
Baby grips your finger with surprising strength
Finger in palm → infant grasps; fades 3–4 months.
Moro (Startle) Reflex
Example
Drop baby's head slightly, arms fly out symmetrically then wrap — normal; if only one arm extends, assess for fracture
Sudden jarring or head drop → symmetric arm abduction & extension, then embrace (C-shaped thumb-index). Disappears 6 months. ASYMMETRY = clavicle fracture or brachial plexus (Erb) palsy.
Tonic Neck (Fencing) Reflex
Example
Turn baby's head right, right arm straightens, left arm bends
Turn head to one side → same-side arm/leg extend, opposite flex. Fades 4 months.
Babinski Reflex
Example
Stroke infant's sole, big toe goes up and others fan out = normal; in adult would suggest stroke
Stroke sole of foot → toes FAN OUT (dorsiflexion of great toe). NORMAL in infants; disappears ~1 year. In adults, fanning = abnormal (upper motor neuron lesion).
Plantar Grasp
Example
Press sole of foot, toes curl inward
Pressure on sole → toes curl. Fades 8 months.
Stepping/Dancing Reflex
Example
Hold baby's feet on table, baby makes stepping movements
Hold baby upright with feet touching surface → stepping motions. Disappears 2 months.
Diagrams to know
- Newborn reflex chart (reflex name, stimulus, response, disappearance age)
- Moro reflex stages (arm abduction → embrace)
Gestational Age Assessment (New Ballard Score)
Common values
Value
37–42 weeks
Symbol
GA
Quantity
Term gestation
Value
<37 weeks
Symbol
GA
Quantity
Preterm definition
Value
>42 weeks
Symbol
GA
Quantity
Post-term definition
Value
<10th percentile
Symbol
%ile
Quantity
SGA percentile cutoff
Value
>90th percentile
Symbol
%ile
Quantity
LGA percentile cutoff
Important facts
- New Ballard Score estimates gestational age from physical + neuromuscular maturity signs
- Score best done within 12 hours (very preterm) to 96 hours after birth
- Physical maturity = skin, lanugo, plantar creases, breast tissue, ear/eye, genitalia
- Neuromuscular maturity = posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear
- Preterm + SGA = compounded risk; post-term + LGA = birth trauma and metabolic risk
- Plot weight against gestational age to classify SGA/AGA/LGA
- Accurate dating crucial because management differs by gestational age and growth pattern
Key definitions
Preterm Infant
Example
Baby born at 35 weeks
<37 weeks gestation.
Term Infant
Example
Baby born at 40 weeks
37–42 weeks gestation (some sources 38–42 weeks); also called full-term.
Post-Term Infant
Example
Baby born at 43 weeks
>42 weeks gestation; at risk for meconium aspiration and hypoglycemia.
Small-for-Gestational-Age (SGA)
Example
37-week baby weighing 1,800 g (below 10th percentile for age)
Weight <10th percentile for gestational age; increased risk for hypoglycemia, hypothermia, and IUGR complications.
Appropriate-for-Gestational-Age (AGA)
Example
40-week baby weighing 3,400 g
Weight 10th–90th percentile for gestational age.
Large-for-Gestational-Age (LGA)
Example
38-week baby weighing 4,200 g (above 90th percentile)
Weight >90th percentile for gestational age; often seen in infants of diabetic mothers (IDM); at risk for hypoglycemia and birth trauma.
New Ballard Score
Example
Scored on skin, lanugo, plantar creases, breast, ear/eye, genitalia (physical) + posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear (neuromuscular)
Scoring system combining physical maturity (6 signs) + neuromuscular maturity (6 signs) to estimate gestational age. Best within 12 hours of birth for very preterm, up to 96 hours.
Diagrams to know
- New Ballard Score scoring grid (physical + neuromuscular maturity)
- Gestational age classification chart (preterm, term, post-term)
- Growth chart placement (SGA, AGA, LGA by percentile)
Immediate Newborn Care — EINC/Unang Yakap Protocol (DOH, Philippines)
Common values
Value
Within 30 seconds
Symbol
t
Quantity
Drying time
Value
1–3 minutes (wait for pulsations to stop)
Symbol
t
Quantity
Cord clamping delay
Value
Ideally within 90 min
Symbol
t
Quantity
First breastfeed timing
Value
6 hours (ideally 24)
Symbol
t
Quantity
Bath delay minimum
Important facts
- EINC discourages unnecessary early routines: aggressive suctioning of vigorous baby, early bathing, routine footprinting, separation
- DELAY FIRST BATH at least 6 hours (ideally 24) to preserve temperature and skin flora
- Immediate drying is THE PRIORITY action for warmth
- Skin-to-skin contact is superior to radiant warmers for thermoregulation
- Delayed cord clamping improves iron stores; do not rush
- Early breastfeeding (within 90 min) supports establishment of milk supply and feeding relationship
- Rooming-in facilitates lactation, bonding, and observation by mother
- Vitamin K, eye ointment, and initial newborn screening done during skin-to-skin or shortly after
Key definitions
EINC (Essential Intrapartum and Newborn Care)
Example
Four core steps done in first 30 min–few hours of life
Philippine DOH protocol called 'Unang Yakap' (First Embrace); standardizes immediate newborn care steps.
Immediate Drying (Step 1)
Example
Wipe amniotic fluid and blood; use prewarmed blankets
Dry newborn thoroughly within 30 seconds of birth to stimulate breathing and PREVENT HEAT LOSS — single most important action for thermoregulation.
Skin-to-Skin Contact (Step 2)
Example
Baby on mother's chest for at least 90 min continuous or until first feed
Place naked baby prone on mother's bare chest/abdomen; cover both with blankets. Provides warmth, bonding, and colonization with maternal flora. Can start immediately after drying.
Delayed Cord Clamping (Step 3)
Example
Wait 1 min at minimum; continue if pulsations present up to 3 min
Clamp and cut umbilical cord AFTER pulsations stop (approximately 1–3 minutes). Improves fetal iron stores, reduces anemia. Do NOT rush.
Non-Separation for Early Breastfeeding (Step 4)
Example
Baby rooms with mother; first feed before 90 min if possible
Keep mother and baby together (rooming-in); initiate breastfeeding ideally within 90 min. Supports bonding, breast milk colonization, and metabolic stabilization.
Diagrams to know
- EINC 4-step flowchart with timing
- Heat loss prevention pathways (evaporation, conduction, convection, radiation)
Thermoregulation — Preventing Cold Stress
Common values
Value
36.5–37.5°C
Symbol
T
Quantity
Axillary temp target
Value
<36.5°C
Symbol
T
Quantity
Hypothermia (mild)
Value
Varies by age/weight (~32–34°C for young newborn under warmer)
Symbol
NTE
Quantity
Neutral thermal zone
Important facts
- Newborns have large surface area, thin skin, minimal fat → rapid heat loss
- Brown fat is metabolized for heat; glucose is consumed → hypoglycemia risk
- Cold stress causes RR ↑, HR ↑, metabolic acidosis, respiratory distress, hypoglycemia — PREVENT at all costs
- Immediate drying PREVENTS EVAPORATION — the single biggest heat loss route
- Head is major heat-loss area → apply cap; skin-to-skin contact includes maternal warmth
- Keep environment warm (radiant warmer if available), blankets prewarmed, hands warm
- Avoid baths <6 hours; delay first bath 24 hours if possible
- Preterm and SGA infants especially vulnerable to cold stress; maintain strict temperature control
Key definitions
Non-Shivering Thermogenesis
Example
Exposed to cold, baby metabolizes brown fat to stay warm (uses glucose and oxygen)
Newborn's mechanism to generate heat by metabolizing brown fat (at nape, axillae, interscapular region) when cold. Infants cannot shiver.
Cold Stress
Example
Newborn in cold environment → RR ↑, HR ↑, poor feeding, lethargy, tremors
Excessive heat loss causing increased oxygen consumption, glucose depletion, metabolic acidosis, respiratory distress, and hypoglycemia. Life-threatening if prolonged.
Neutral Thermal Environment (NTE)
Example
For 1-day-old newborn ~3 kg: NTE approximately 32–34°C under radiant warmer
Temperature range where newborn maintains normal body temperature with minimal metabolic work; depends on age, weight, and clothing.
Heat Loss by Evaporation
Example
Wet newborn loses heat rapidly; drying stops evaporation
Loss of heat as amniotic fluid or water evaporates from skin. Prevention: immediate drying with prewarmed blankets.
Heat Loss by Conduction
Example
Place baby on cold metal scale → heat transfers; use warmed scale liner or blanket
Transfer of heat to cold surfaces (scale, examination table, cold hands). Prevention: warm scale, blankets, hands.
Heat Loss by Convection
Example
Baby in draft from open window → heat lost; close drafts
Loss of heat to moving air (drafts, air-conditioning). Prevention: avoid drafts; keep away from AC vents.
Heat Loss by Radiation
Example
Crib near cold window → infant loses heat to window; move crib to interior wall
Loss of heat to cold objects not touching infant (cold windows, outer walls). Prevention: position away from cold surfaces; use radiant warmer.
Diagrams to know
- Four heat loss pathways (evaporation, conduction, convection, radiation) and prevention
- Cold stress cascade (hypothermia → hypoglycemia → metabolic acidosis → respiratory distress)
Prophylactic Medications at Birth
Common values
Value
0.5–1 mg IM (usually 1 mg)
Symbol
Dose
Quantity
Vitamin K dose
Value
Intramuscular
Symbol
Route
Quantity
Vitamin K route
Value
Vastus lateralis (outer thigh)
Symbol
Site
Quantity
Vitamin K site
Value
Within 24 hours
Symbol
t
Quantity
Hep B vaccine timing
Value
0.5% solution to both eyes, once
Symbol
Dose
Quantity
Erythromycin eye ointment
Important facts
- Vitamin K dose is 0.5–1 mg IM (most protocols use 1 mg), vastus lateralis preferred
- Erythromycin eye ointment applied to BOTH eyes; do not irrigate off
- If mother has gonorrhea or chlamydia, eye prophylaxis is MANDATORY
- Hepatitis B vaccine first dose within 24 hours; subsequent doses follow EPI schedule (6 weeks, 10 weeks, 14 weeks)
- BCG vaccine given intradermally (not IM); watch for local reaction (pustule ~2 weeks, then scar)
- Do NOT delay vaccines for minor reasons; Philippine EPI schedule is strict
- Document all prophylactic meds in infant record with time, route, site, and lot number
- If mother is GBS+ or has active genital herpes, additional protocols apply (beyond basic prophylaxis)
Key definitions
Vitamin K (Phytonadione)
Example
Give 1 mg IM; prevents late-onset bleeding (day 2–7) from vitamin K deficiency
Dose 0.5–1 mg IM (usually 1 mg) in vastus lateralis, given once at birth. Prevents vitamin K–deficiency bleeding (hemorrhagic disease of the newborn). The gut is sterile at birth and cannot synthesize vitamin K.
Vitamin K–Deficiency Bleeding (Hemorrhagic Disease of the Newborn)
Example
Untreated infant may have melena, hematuria, intracranial hemorrhage by day 2–7
Bleeding tendency in first days of life due to lack of intestinal flora (needed for vitamin K synthesis) and immature hepatic prothrombin synthesis. Prevented by prophylactic vitamin K.
Erythromycin 0.5% Ophthalmic Ointment
Example
Squeeze small amount into both eyes; prevents neonatal gonorrhea/chlamydia conjunctivitis
Applied to both eyes immediately after birth to prevent ophthalmia neonatorum (gonococcal or chlamydial conjunctivitis from mother's birth canal). One-time application.
Hepatitis B Vaccine (First Dose)
Example
0.5 mL IM (or dose per product) in anterolateral thigh; schedule 2nd and 3rd doses
Given within 24 hours of birth (part of Philippine EPI); protects against HBV transmission from mother or environment.
BCG Vaccine (at Birth)
Example
0.05 mL intradermally at birth; watch for local reaction
Bacillus Calmette-Guérin vaccine; given at birth per Philippine EPI to prevent tuberculosis.
Diagrams to know
- Prophylactic med checklist (Vit K, eye ointment, Hep B, BCG with timing)
- Philippine EPI schedule at birth and early weeks
Newborn Screening (RA 9288 — Newborn Screening Act of 2004)
Common values
Value
24–72 hours after birth
Symbol
t
Quantity
Sample collection window
Value
If <24 hours, MUST repeat
Symbol
Repeat
Quantity
Early collection requirement
Value
6 (CH, CAH, GAL, PKU, G6PD, MSUD)
Symbol
n
Quantity
Basic screening panel disorders
Value
28+
Symbol
n
Quantity
Expanded panel disorders
Important facts
- Heel-prick sample collected 24–72 hours AFTER BIRTH (not before 24 hours); if <24 hours, repeat
- Sample is dried blood spots on filter paper; must be handled and stored per protocol
- Nurse MUST inform and obtain INFORMED CONSENT from parents before screening
- Core basic panel (RA 9288): CH, CAH, GAL, PKU, G6PD deficiency, MSUD
- Expanded panel now available, covers 28+ conditions
- Early detection and immediate treatment prevent intellectual disability, death, and seizures
- Follow-up confirmatory testing required for abnormal results; repeat screening may be needed
- Results communicated to mother and referred to pediatrician/specialist; confidentiality maintained
- Document sample collection time, name, age, facility, and results in infant record
Key definitions
RA 9288 (Newborn Screening Act of 2004)
Example
Every newborn in PH screened for congenital hypothyroidism, PKU, galactosemia, CAH, G6PD deficiency, MSUD
Philippine law institutionalizing mandatory newborn screening for treatable metabolic/endocrine disorders. Early detection allows treatment before irreversible disability.
Newborn Screening Sample Collection Timing
Example
Born at 08:00 Day 1 → sample between 08:00 Day 2 to 08:00 Day 3
Heel-prick blood sample collected BETWEEN 24–72 HOURS after birth (at least 24 hours old so feeding-dependent metabolites register accurately). If drawn <24 hours, MUST repeat.
Congenital Hypothyroidism (CH)
Example
Screening shows low T4 → start levothyroxine immediately; child develops normally
Deficiency of thyroid hormone from birth; causes intellectual disability, growth delay if untreated. Detected on screening via low T4 or high TSH. Early treatment with levothyroxine prevents disability.
Congenital Adrenal Hyperplasia (CAH)
Example
Screening shows elevated 17-OH progesterone → start steroid therapy; normal development
Deficiency of enzyme (usually 21-hydroxylase) in cortisol synthesis; causes virilization in females, salt wasting, and shock if untreated. Detected via high 17-OH progesterone. Treatment with hydrocortisone and fludrocortisone.
Phenylketonuria (PKU)
Example
Screening shows elevated phenylalanine → start special diet; normal development possible
Deficiency of enzyme phenylalanine hydroxylase; causes high phenylalanine, intellectual disability, seizures, eczema, musty odor if untreated. Low-phenylalanine diet prevents disability.
Galactosemia (GAL)
Example
Screening shows elevated galactose → switch to lactose-free formula immediately
Deficiency of enzyme for galactose metabolism; causes cataracts, intellectual disability, hepatosplenomegaly, neonatal sepsis if untreated. Lactose-free formula prevents disability.
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency
Example
Screening shows G6PD deficiency → counsel parents to avoid sulfa drugs and fava beans
Genetic enzyme deficiency (X-linked); causes hemolysis when exposed to oxidative triggers (sulfa drugs, fava beans). Identified via low enzyme level. Management: avoid triggers.
Maple Syrup Urine Disease (MSUD)
Example
Screening shows elevated branched-chain amino acids → start MSUD diet formula
Deficiency of branched-chain amino acid dehydrogenase; causes elevated branched-chain amino acids (isoleucine, leucine, valine), cerebral edema, developmental delay if untreated. Specialized amino acid-restricted diet prevents disability.
Expanded Newborn Screening Panel
Example
RA 9288 originally covered 6 (CH, CAH, GAL, PKU, G6PD, MSUD); expanded panel adds sickle cell, carnitine deficiency, and others
Extended version of basic newborn screening; now detects 28+ disorders (includes sickle cell disease, other hemoglobinopathies, fatty acid oxidation defects, organic acidemias, and more).
Diagrams to know
- RA 9288 basic screening panel (6 core conditions) and expanded panel
- Newborn screening process flow (collection → test → results → follow-up)
- Timing for screening (born → 24–72 hours → sample collection)
Normal Variations (Reassure) vs. Abnormal Signs (Report)
Common values
Value
2–4 weeks (spontaneous resolution)
Symbol
t
Quantity
Milia duration
Value
Typically disappears by school age
Symbol
t
Quantity
Mongolian spot duration
Value
24–72 hours after birth
Symbol
t
Quantity
Erythema toxicum onset
Value
Days
Symbol
t
Quantity
Caput succedaneum resolution
Value
3–6 months
Symbol
t
Quantity
Cephalohematoma resolution
Important facts
- DISTINGUISH: Caput succedaneum CROSSES SUTURE LINES; cephalohematoma DOES NOT cross sutures
- Cephalohematoma increases jaundice risk from blood breakdown; monitor bilirubin closely
- Mongolian spots common in Filipino infants; DOCUMENT to prevent confusion with abuse
- Acrocyanosis is NORMAL; CENTRAL cyanosis (face/trunk blue) is ABNORMAL — report
- Swollen breasts/genitalia in newborns (both sexes) from maternal hormones; reassure parents
- Milia on nose/chin = normal; do NOT squeeze or extract
- Erythema toxicum is benign rash; disappears spontaneously, no antibiotic needed
- Normal variations reassure; abnormal signs (bulging fontanelle, RR >60, grunting) trigger investigation
Key definitions
Milia
Example
Newborn has small white bumps on nose bridge — normal, no treatment
Tiny white sebaceous cysts on nose, chin, forehead; benign, disappear spontaneously in 2–4 weeks. Do NOT extract.
Mongolian Spot
Example
Filipino newborn has blue-gray mark over buttocks — normal, document with location/size
Bluish-gray pigmentation over sacrum, buttocks, flanks; more common in Filipino and darker-skinned infants. Benign, typically disappears by school age. DOCUMENT to differentiate from bruising.
Erythema Toxicum
Example
Newborn has red blotchy rash with white centers on chest — normal, reassure parents
Benign newborn rash; red macules with white centers (resembles flea bites) appearing 24–72 hours after birth. Disappears in 1–2 weeks. No treatment needed.
Caput Succedaneum
Example
Newborn's scalp is puffy and crosses the fontanelle border — normal, will decrease
Scalp edema from birth trauma/prolonged labor; CROSSES SUTURE LINES. Resolves within days. Pitting edema may be present. No treatment.
Cephalohematoma
Example
Newborn has firm swelling over parietal bone that doesn't cross sutures — normal finding but monitor for jaundice
Bleeding under periosteum from subperiosteal hemorrhage (birth trauma); DOES NOT CROSS SUTURE LINES; boggy, firm swelling. Resolves in 3–6 months. Watch for hyperbilirubinemia from blood breakdown.
Pseudomenstruation
Example
Mother reports 'bleeding' from infant's vagina first 2–3 days — normal, explain withdrawal bleeding
Vaginal bleeding or mucous discharge in female newborns from maternal estrogen withdrawal. Self-limiting, reassure parents.
Physiologic Peeling/Desquamation
Example
Newborn's skin is peeling slightly — normal, explain it will resolve
Peeling or scaling of skin, especially after 24 hours; normal shedding of old skin. Most prominent in post-term infants. No treatment.
Acrocyanosis
Example
Baby's fingers and toes are blue but face is pink — normal; if baby's face is blue, report immediately
Blue discoloration of hands and feet in first 24 hours; benign, result of sluggish peripheral perfusion. Central cyanosis (blue face/trunk) is ABNORMAL.
Diagrams to know
- Normal vs. abnormal newborn findings checklist (caput vs. cephalohematoma, acrocyanosis vs. central cyanosis)
- Mongolian spot vs. bruising differentiation guide
Must remember
- APGAR is scored at 1 min and 5 min; 7–10 = good, 4–6 = moderately depressed, 0–3 = severely depressed. Acrocyanosis (blue hands/feet only) is NORMAL and costs 1 point, not a sign of hypoxia. Resuscitation is guided by HR and breathing, NOT by APGAR timing.
- Normal newborn vitals: HR 110–160 bpm (apical, count 60 sec), RR 30–60 breaths/min (irregular, abdominal), axillary temp 36.5–37.5°C, glucose >45 mg/dL. Weight 2,500–4,000 g; head circumference 2–3 cm LARGER than chest circumference.
- EINC/Unang Yakap 4 CORE steps in order: (1) Immediate drying within 30 sec to prevent heat loss, (2) Skin-to-skin contact on mother's bare chest, (3) Delayed cord clamping (1–3 min until pulsations stop), (4) Non-separation for early breastfeeding within 90 min. Delay first bath ≥6 hours.
- Thermoregulation is critical: prevent four heat-loss pathways (evaporation, conduction, convection, radiation). Drying is THE PRIORITY. Cold stress causes increased O₂ consumption, hypoglycemia, respiratory distress, metabolic acidosis. Brown fat metabolism generates heat; glucose is consumed.
- Prophylactic medications at birth: Vitamin K 0.5–1 mg IM (usually 1 mg, vastus lateralis) prevents hemorrhagic disease of the newborn; erythromycin 0.5% eye ointment to both eyes prevents ophthalmia neonatorum; Hepatitis B vaccine within 24 hours; BCG at birth per Philippine EPI.
- RA 9288 (Newborn Screening Act) basic panel: 6 core disorders (CH, CAH, GAL, PKU, G6PD deficiency, MSUD). Sample collected 24–72 hours after birth via heel-prick (must be ≥24 hours old; if <24 hours, repeat). Early detection prevents intellectual disability and death. Expanded panel now covers 28+ disorders.
- Newborn reflexes: Rooting, sucking, palmar grasp, moro (symmetric arm abduction/extension then embrace), tonic neck (fencing), Babinski (toe fanning = normal in infants), plantar grasp, stepping. ASYMMETRIC Moro = RED FLAG for clavicle fracture or brachial plexus (Erb) palsy. Babinski toe fanning is normal in infants but abnormal in adults.
- DISTINGUISH: Caput succedaneum CROSSES SUTURE LINES, soft pitting, resolves in days; cephalohematoma DOES NOT cross sutures, boggy/firm, resolves in 3–6 months (increases jaundice risk from blood breakdown). Mongolian spots (bluish sacrum/buttocks) are normal in Filipino infants — DOCUMENT to prevent confusion with abuse.
- New Ballard Score estimates gestational age from physical maturity (skin, lanugo, plantar creases, breast, ear/eye, genitalia) + neuromuscular maturity (posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear). Best within 12 hours (very preterm) to 96 hours. Plot weight against GA to classify SGA (<10th %ile), AGA (10–90th %ile), LGA (>90th %ile).
- Central cyanosis (face/trunk/lips blue) is ABNORMAL and requires immediate action; acrocyanosis (hands/feet blue only) is NORMAL in first 24 hours. Distinguish: acrocyanosis = peripheral, benign; central = hypoxemia, report immediately. Normal variations to reassure (milia, erythema toxicum, physiologic peeling) vs. abnormal signs to report (bulging fontanelle, RR >60, grunting, central cyanosis).
Last minute tips
- APGAR acrocyanosis trap: Do NOT score a baby as 0 (blue/pale all over) when hands and feet are blue but the body is pink — that is acrocyanosis = 1 point, normal, and very common in the first 24 hours. Acrocyanosis is NOT central cyanosis.
- Resuscitation timing trap: The APGAR score does NOT determine when to start resuscitation. Resuscitation begins IMMEDIATELY at birth if HR is not detectable or <100 bpm, or if breathing is absent/inadequate. The 1-minute APGAR score is ASSIGNED AFTER resuscitation is underway, not before.
- Cord clamping trap: 'Delayed cord clamping' means waiting 1–3 minutes for pulsations to stop, NOT clamping immediately. This improves fetal iron stores. Do NOT rush to clamp — wait and watch for pulsations to fade. Premature clamping deprives the infant of maternal blood volume.
- Newborn screening timing trap: Heel-prick sample MUST be collected between 24–72 hours after birth (at least 24 hours old). If collected before 24 hours, the sample is INVALID and MUST be repeated. This is a high-yield NLE question: 'A 6-hour-old baby's newborn screening sample arrives at the lab. Action?' → REPEAT, sample too early.
- Moro reflex trap: An asymmetric Moro (one arm extends, the other does not, or unequal movement) is a RED FLAG for birth trauma: fractured clavicle (palpate clavicles for crepitus) or Erb palsy (brachial plexus injury). Do NOT dismiss as normal variation — report and investigate immediately.
Comparison tables
APGAR Score Interpretation & Management
| APGAR Score | Classification | Immediate Action | Nursing Considerations |
|---|---|---|---|
| 7–10 | Good adaptation | Routine care only; place skin-to-skin with mother | Normal vital signs, no respiratory distress; begin Unang Yakap protocol |
| 4–6 | Moderately depressed | Stimulation, airway clearance, oxygen, assisted ventilation may be needed; reassess at 5 min | Monitor closely; may need nasal prongs or bag-mask ventilation; recheck HR and breathing |
| 0–3 | Severely depressed | Immediate active resuscitation: airway, breathing, circulation per NRP (endotracheal tube, chest compressions) | Transfer to resuscitation area; coordinate with pediatrician/neonatologist; prepare for NICU |
Caput Succedaneum vs. Cephalohematoma
| Feature | Caput Succedaneum | Cephalohematoma |
|---|---|---|
| Cause | Scalp edema from birth trauma/prolonged labor | Bleeding under periosteum (subperiosteal hemorrhage) |
| Suture crossing | CROSSES suture lines | DOES NOT cross suture lines |
| Appearance | Soft, pitting edema | Boggy, firm, fluctuant swelling |
| Resolution time | Days (1–3) | 3–6 months |
| Jaundice risk | Minimal | Increased (monitor bilirubin; blood breakdown causes hyperbilirubinemia) |
| Treatment | None; reassure | Observation; monitor for infection/calcification; close bilirubin monitoring |
Acrocyanosis vs. Central Cyanosis
| Feature | Acrocyanosis (Normal) | Central Cyanosis (Abnormal) |
|---|---|---|
| Location | Hands and feet only (periphery) | Face, trunk, lips, tongue (core/central) |
| Timing | First 24 hours normal; can persist longer | At any time = abnormal |
| Cause | Sluggish peripheral perfusion from vasoconstriction (benign) | Hypoxemia (low oxygen); respiratory or cardiac problem |
| Action | Reassure parents; monitor temperature | IMMEDIATE report; oxygen, close monitoring, possible resuscitation |
| APGAR impact | Costs 1 point (body pink, extremities blue = 1) | Scores 0 (blue/pale all over) |
Newborn Screening (RA 9288) — Core 6 Disorders
| Disorder | Abbreviation | Cause | Effect if Untreated | Screening Method | Treatment |
|---|---|---|---|---|---|
| Congenital Hypothyroidism | CH | Thyroid hormone deficiency | Intellectual disability, growth delay, developmental delay | Low T4 or elevated TSH | Levothyroxine therapy |
| Congenital Adrenal Hyperplasia | CAH | Enzyme deficiency (21-hydroxylase), abnormal cortisol synthesis | Virilization (females), salt wasting, shock, intellectual disability | Elevated 17-OH progesterone | Hydrocortisone + fludrocortisone |
| Phenylketonuria | PKU | Phenylalanine hydroxylase deficiency; high phenylalanine | Intellectual disability, seizures, eczema, musty odor | Elevated phenylalanine | Low-phenylalanine diet |
| Galactosemia | GAL | Enzyme deficiency in galactose metabolism | Cataracts, intellectual disability, hepatosplenomegaly, neonatal sepsis | Elevated galactose | Lactose-free formula |
| Glucose-6-Phosphate Dehydrogenase Deficiency | G6PD | X-linked enzyme deficiency | Hemolysis when exposed to oxidative triggers (sulfa drugs, fava beans) | Low enzyme activity | Avoid triggers; counsel parents |
| Maple Syrup Urine Disease | MSUD | Branched-chain amino acid dehydrogenase deficiency; elevated isoleucine, leucine, valine | Cerebral edema, developmental delay, neurologic damage | Elevated branched-chain amino acids | Specialized amino acid-restricted diet |
Gestational Age Classifications & Associated Risks
| Classification | Gestational Age | Key Risks | Nursing Priorities |
|---|---|---|---|
| Preterm | <37 weeks | Respiratory distress, hypothermia, hypoglycemia, poor feeding, brain immaturity, intraventricular hemorrhage | Strict thermoregulation, frequent glucose/temp checks, respiratory monitoring, possible NICU transfer |
| Term | 37–42 weeks | Minimal (well adapted to extrauterine life) | Routine newborn care, EINC protocol, standard screening, normal observation |
| Post-Term | >42 weeks | Meconium aspiration (in utero defecation/inhalation), hypoglycemia, growth restriction, oligohydramnios complications | Monitor for meconium-stained fluid, respiratory distress, hypoglycemia checks, possible intervention |
| SGA + Preterm (double risk) | Weight <10th percentile + <37 weeks | Compounded hypoglycemia, hypothermia, respiratory, neurologic risk | Intensive monitoring: glucose q30–60 min initially, continuous temperature support, respiratory monitoring |
Diagrams
APGAR Score Interpretation & Immediate Action
This flowchart shows the APGAR scoring timeline (1 min, 5 min) and immediate nursing actions based on the score. Key: resuscitation begins based on HR and breathing at birth (not after waiting for 1-min APGAR), and the score guides ongoing observation and care level. Scores 7–10 proceed to routine Unang Yakap; 4–6 get support and reassessment; 0–3 go to resuscitation.
Normal Newborn Assessment Components
This mind map provides a comprehensive visual overview of all major components of normal newborn assessment and care. It branches into APGAR, vital signs, reflexes, gestational age assessment, EINC protocol, prophylactic medications, and RA 9288 newborn screening — the six foundational pillars of newborn nursing.
EINC/Unang Yakap Protocol — 4 Core Steps with Timing
Step-by-step flowchart of the Philippine EINC/Unang Yakap protocol showing the 4 core time-bound steps: (1) immediate drying within 30 sec, (2) skin-to-skin contact immediately, (3) delayed cord clamping (1–3 min), (4) early breastfeeding within 90 min. Key: all steps are sequential and time-specific. First bath is delayed ≥6 hours.
Thermoregulation & Cold Stress Cascade
State diagram showing the cascade from normal temperature through cold stress to potential crisis. Key: cold exposure leads to hypothermia, which triggers brown fat metabolism (consuming glucose), causing hypoglycemia and metabolic acidosis, followed by respiratory distress. Prevention of four heat-loss pathways (evaporation, conduction, convection, radiation) is essential. Intervention: drying, warming, cap, avoid drafts.