Newborn Assessment: APGAR, Vitals, Jaundice & Hypoglycemia (Maternity)

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.

1. Overview: Transition to Extrauterine Life

At birth the newborn must start breathing, switch circulation, and keep itself warm and fed.

Breathing: fluid clears from the lungs; the first breaths open alveoli (helped by )
Circulation: lung pressure falls and left-heart pressure rises → the foramen ovale and ductus arteriosus close over hours to days (late or failed closure → murmurs, CHD; see Pediatrics)
Temperature: newborns lose heat fast (large surface area, little fat) and make heat by burning (non-shivering thermogenesis), which uses glucose and oxygen. Cold stress → hypoglycemia, hypoxia, acidosis
Glucose: the placental supply stops; blood glucose normally dips in the first 1–2 h, then stabilizes with feeding

2. APGAR Score

Scored at 1 and 5 minutes (and every 5 min to 20 min if the 5-min score is < 7). It does not decide whether to resuscitate — start resuscitation immediately if the baby isn’t breathing well.

Sign	0	1	2
Appearance (color)	Blue/pale all over	Body pink, extremities blue ()	Pink all over
Pulse	Absent	< 100	≥ 100
Grimace (reflex irritability)	No response	Grimace	Cry, cough, sneeze
Activity (tone)	Limp	Some flexion	Active motion
Respiration	Absent	Slow, irregular, weak cry	Good, strong cry

7–10 reassuring; 4–6 moderately abnormal; 0–3 low. Acrocyanosis is common in the first day — most healthy newborns score 8–9.

3. Normal Newborn Values (typical; vary by source)

Parameter	Typical range
Heart rate	110–160/min (up to ~180 crying, ~85–100 deep sleep) — count apical for 1 full minute
Respirations	30–60/min, irregular; brief pauses < 15–20 s are normal (periodic breathing)
Temperature (axillary)	36.5–37.5 °C (97.7–99.5 °F)
BP	Not routinely taken in healthy term newborns
Weight	~2,500–4,000 g at term. Losing up to ~7–10% by days 3–5 is expected; regain birth weight by ~10–14 days
Length / head circumference	~45–55 cm / ~32–38 cm; chest ~2 cm smaller than head
Blood glucose	Target thresholds vary by age in hours and protocol — commonly treat if < ~40–45 mg/dL in the first day

Respiratory distress signs (report): RR > 60, grunting, nasal flaring, retractions, central cyanosis, apnea > 20 s.

4. Head-to-Toe Highlights

Finding	Normal (variation)	Concerning
Fontanelles	Anterior diamond (closes ~12–18 mo), posterior triangle (closes ~2–3 mo); soft, flat	Bulging (↑ ICP, infection) or sunken (dehydration)
Head swelling	— crosses suture lines, resolves in days	— doesn’t cross sutures; blood → ↑ jaundice risk
Skin	Acrocyanosis, milia, Mongolian spots (document — not bruises), erythema toxicum, stork bites	Central cyanosis, jaundice in the first 24 h, petechiae all over
Cord	2 arteries + 1 vein	2 vessels → evaluate for kidney/heart anomalies
Reflexes	Moro, rooting, sucking, palmar/plantar grasp, Babinski (fanning normal until ~1 yr), stepping	Absent or asymmetrical Moro (clavicle fracture, brachial plexus injury)
Hips	Symmetric gluteal folds; Ortolani/Barlow negative	Clunk or asymmetry →
Gestational age	Ballard score	Small or large for gestational age → glucose checks

Elimination: meconium within 24–48 h; first void within 24 h. By day ~5, expect ≥ 6 wet diapers/day.

5. Routine Newborn Care and Medications

Dry, warm, skin-to-skin; hat; delay bathing (often ≥ 24 h per WHO/facility policy)
Airway: suction mouth first, then nose (“M before N”) only if needed
Vitamin K (phytonadione) IM within ~6 h — newborns can’t make enough → prevents vitamin K deficiency bleeding. Vastus lateralis
Erythromycin eye ointment — prevents gonococcal ophthalmia neonatorum
Hepatitis B vaccine — the birth dose recommendation has been under review in 2025–2026; follow your facility’s current policy and the current CDC schedule. Infants of HBsAg-positive parents receive hepatitis B vaccine plus HBIG within 12 h
Screens before discharge: newborn metabolic blood spot (after 24 h of feeding when possible), hearing, CCHD pulse oximetry (≥ 24 h), bilirubin
Security: matching ID bands; infant abduction protocols; never leave the baby unattended
Safe sleep and car seat teaching (see Pediatrics: Safety)

6. Neonatal Jaundice

Why: newborns have more red cells with a shorter life span, an immature liver (low conjugating enzyme), and more gut reabsorption of bilirubin.

Type	Timing	Notes
Physiologic	Appears after 24 h, peaks ~day 3–5	Common; frequent feeding helps
Pathologic	Within the first 24 h, or rising fast, or prolonged	Hemolysis (Rh/ABO incompatibility, G6PD), infection, cephalohematoma — always report jaundice < 24 h
Breastfeeding-associated	First week	Poor intake → more reabsorption; feed more often (8–12×/day)
Breast milk jaundice	After the first week, may last weeks	Usually benign; evaluate

Assessment: jaundice spreads head-to-toe; blanch skin over the nose/sternum in good light. Measure with transcutaneous or serum bilirubin, interpreted on an hour-specific nomogram with risk factors (AAP 2022).

Phototherapy nursing: expose maximum skin (diaper only), eye shields, turn regularly, monitor temperature, hydration and weight (more insensible water loss), loose green stools are expected, no lotions, turn lights off for blood draws, encourage feeding. Severe/rising levels → exchange transfusion.

Danger: (bilirubin brain injury): lethargy, poor feeding, high-pitched cry, hypertonia/arching. Prevent it.

7. Neonatal Hypoglycemia

At risk: infants of diabetic parents (IDM), large or small for gestational age, preterm, cold-stressed, septic, birth asphyxia.

Signs: jitteriness/tremors, poor feeding, weak or high-pitched cry, hypothermia, hypotonia, lethargy, apnea, cyanosis, sweating, seizures. Many are asymptomatic → screen at-risk babies per protocol.

Nursing: check heel-stick glucose (lateral heel); feed early (breastfeed or formula/colostrum); oral dextrose gel per protocol; recheck after feeding; IV dextrose for severe or persistent lows or symptoms; keep warm.

8. Other Newborn Emergencies

Neonatal resuscitation (NRP): warm, dry, stimulate, position airway, clear secretions if needed. HR < 100 or apnea/gasping → positive-pressure ventilation (ventilation is the priority). HR < 60 despite 30 s of effective ventilation → compressions (3:1 ratio) and 100% O₂
Sepsis: temperature instability (often low), poor feeding, lethargy, respiratory distress — subtle; report early
: high-pitched cry, tremors, poor sleep, sneezing, yawning, feeding problems, diarrhea. “Eat, Sleep, Console” approach: low-stimulation room, swaddling, skin-to-skin, parent at bedside, breastfeeding when appropriate, medication if needed
Hypothermia: skin-to-skin or radiant warmer; check glucose

9. Memory Aids

APGAR = Appearance, Pulse, Grimace, Activity, Respiration (each 0–2)
Newborn “110–160 / 30–60 / 36.5–37.5”
Caput Crosses sutures; cephalohematoma = “halts” at the sutures (and higher bilirubin)
“Yellow in the first day — not okay”
Cold baby = sugar-low baby
NRP: “Breathe for the baby first” — ventilation fixes most newborn bradycardia

10. NCLEX-Style Practice Questions

1. At 1 minute, a newborn has HR 110, a weak irregular cry, some flexion of the limbs, a grimace with suctioning, and blue hands and feet with a pink body. What is the APGAR score?

A. 5
B. 6
C. 7
D. 8

Answer: B. HR > 100 = 2; weak irregular respirations = 1; some flexion = 1; grimace = 1; acrocyanosis = 1. Total 6.

2. A newborn of a mother with diabetes is jittery at 1 hour of age. Which action comes first?

A. Notify the provider of possible seizure activity
B. Check a heel-stick blood glucose
C. Place the infant under phototherapy
D. Give vitamin K

Answer: B. Jitteriness in an infant of a diabetic mother strongly suggests hypoglycemia (the fetus made extra insulin in response to high maternal glucose). Confirm with glucose and feed or treat per protocol.

3. The nurse notes yellow skin on a 16-hour-old newborn. What is the best action?

A. Reassure the parents that this is physiologic jaundice
B. Increase breastfeeding and recheck tomorrow
C. Report the finding to the provider promptly
D. Place the infant near a sunny window

Answer: C. Jaundice within the first 24 hours is pathologic until proven otherwise (often hemolysis). It needs a bilirubin level and evaluation. Sunlight (D) is not a safe treatment.

4. Which actions are correct for an infant receiving phototherapy? Select all that apply.

A. Cover the eyes with protective shields
B. Apply lotion to prevent skin dryness
C. Monitor temperature and hydration closely
D. Keep the infant fully swaddled to stay warm
E. Expect loose, greenish stools

Answer: A, C, E. Shields protect the retinas; phototherapy raises temperature and fluid losses; bilirubin excreted in the stool makes it loose and green. Lotions (B) can cause burns, and swaddling (D) blocks the light.

5. A newborn’s swelling on the scalp crosses the suture line and was present at birth. The parents ask whether it is serious. The nurse explains that this is most likely:

A. A cephalohematoma that may increase jaundice risk
B. Caput succedaneum, which usually resolves in a few days
C. A skull fracture requiring imaging
D. Hydrocephalus

Answer: B. Caput succedaneum is scalp edema from pressure during birth; it crosses suture lines and resolves within days. A cephalohematoma does not cross sutures.

References

Ansong-Assoku, B., Adnan, M., Daley, S. F., & Ankola, P. A. (2024). Neonatal jaundice. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532930/

Kasala, S., Ward, R., & Shah, M. (2026). Neonatal hypoglycemia. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537105/

Kemper, A. R., Newman, T. B., Slaughter, J. L., Maisels, M. J., Watchko, J. F., Downs, S. M., Grout, R. W., Bundy, D. G., Stark, A. R., Bogen, D. L., Holmes, A. V., Feldman-Winter, L. B., Bhutani, V. K., Brown, S. R., Maradiaga Panayotti, G. M., Okechukwu, K., Rappo, P. D., & Russell, T. L. (2022). Clinical practice guideline revision: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 150(3), e2022058859. https://doi.org/10.1542/peds.2022-058859

National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page

Simon, L. V., Shah, M., & Bragg, B. N. (2026). APGAR score. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470569/