Neonatal Assessment
Step 1: Assess ABCs (Airway, Breathing, Circulation)
• Make sure airway patent, no obstruction
• Assess COLOR
• Assess MUSCLE TONE (make sure they aren’t completely limp, flexed position)
Step 2: Check 2 ID Bands (On each baby’s ankle, make sure each match
with mom's)
• Baby should NOT leave room without both ID bands
Step 3: APGAR: assessed at 1 min and at 5 min after birth
• Total score ranges from 1-10
• Goal: >7!
• Each section “letter:” 0-2
A = Appearance
• Color, Tone
P = Pulse
• Auscultate heart sounds
• Feel base of umbilicus and feel pulsations
• Normal heart rate > 100 beats per min
G = Grimace
• Are they crying? - Want them to be crying that is a good sign
• Reacting or flaccid?
A = Activity
• Make sure they are in a nice, flexed position, not flaccid (soft/limp)
• Reacting or flaccid?
• Awake and alert?
R = Respiratory Status
• Newborns are abdominal breathers, make sure abdomen is moving up and down and
looks like they are breathing effectively. Make sure baby not using accessory muscles.
Step 4: "Golden Hour" = Baby skin to skin with mom & start feeding
, Step 5: Medications
A. Erythromycin: put ointment on eyes to prevent bacterial infection
• Open both eyelids
• Put in subconjunctival sac, right under lower eyelids
• Squeeze from inner canthus to outer canthus, don’t wipe extra away
• Blink to distribute into eye
B. Vitamin K injection: helps with blood clotting, because babies born with low
levels of vitamin K
• IM in vastus lateralis (middle outer thigh)
• 90 degree angle
C. Hepatitis B Vaccine: IM injection
• IM in vastus lateralis (middle outer thigh)
• Give in other thigh, not the one you gave Vitamin K injection
• 90 degree angle
Step 6: Measurements
A. Weight/Scale in lb and g
• Avg weight: 7 lb (3.2 kg or 3200g)
• Have scale next to you and zero it.
• Make sure scale covered by blanket or Chux pad
• You can also put a diaper, zero it out.
• Then when you put baby on it, it is just the baby’s weight not including diaper.
• Scale/Record in grams and pounds
B. Length in cm
• Avg length: 7 lb (48.2-50.8 cm)
• Sometimes done on scale if there’s a ruler on the actual scale
• OR make sure baby is positioned correctly and can measure from top of head to
bottom of feet/heel when foot is outstretched
• Take baby, draw where top of head is with a pen on sheet or Chucx pad, and draw
where heel is, and use measuring tape from 2 points you marked on pad with pen to
get a more accurate measurement cause baby isn’t moving around
C. Head Circumference in cm
• Avg: 34.5 cm
• Sit up baby, have widest part of head.
• FOC = front occipital circumference: right above eyebrow all the way around with
tape measure
D. Chest Circumference
Step 1: Assess ABCs (Airway, Breathing, Circulation)
• Make sure airway patent, no obstruction
• Assess COLOR
• Assess MUSCLE TONE (make sure they aren’t completely limp, flexed position)
Step 2: Check 2 ID Bands (On each baby’s ankle, make sure each match
with mom's)
• Baby should NOT leave room without both ID bands
Step 3: APGAR: assessed at 1 min and at 5 min after birth
• Total score ranges from 1-10
• Goal: >7!
• Each section “letter:” 0-2
A = Appearance
• Color, Tone
P = Pulse
• Auscultate heart sounds
• Feel base of umbilicus and feel pulsations
• Normal heart rate > 100 beats per min
G = Grimace
• Are they crying? - Want them to be crying that is a good sign
• Reacting or flaccid?
A = Activity
• Make sure they are in a nice, flexed position, not flaccid (soft/limp)
• Reacting or flaccid?
• Awake and alert?
R = Respiratory Status
• Newborns are abdominal breathers, make sure abdomen is moving up and down and
looks like they are breathing effectively. Make sure baby not using accessory muscles.
Step 4: "Golden Hour" = Baby skin to skin with mom & start feeding
, Step 5: Medications
A. Erythromycin: put ointment on eyes to prevent bacterial infection
• Open both eyelids
• Put in subconjunctival sac, right under lower eyelids
• Squeeze from inner canthus to outer canthus, don’t wipe extra away
• Blink to distribute into eye
B. Vitamin K injection: helps with blood clotting, because babies born with low
levels of vitamin K
• IM in vastus lateralis (middle outer thigh)
• 90 degree angle
C. Hepatitis B Vaccine: IM injection
• IM in vastus lateralis (middle outer thigh)
• Give in other thigh, not the one you gave Vitamin K injection
• 90 degree angle
Step 6: Measurements
A. Weight/Scale in lb and g
• Avg weight: 7 lb (3.2 kg or 3200g)
• Have scale next to you and zero it.
• Make sure scale covered by blanket or Chux pad
• You can also put a diaper, zero it out.
• Then when you put baby on it, it is just the baby’s weight not including diaper.
• Scale/Record in grams and pounds
B. Length in cm
• Avg length: 7 lb (48.2-50.8 cm)
• Sometimes done on scale if there’s a ruler on the actual scale
• OR make sure baby is positioned correctly and can measure from top of head to
bottom of feet/heel when foot is outstretched
• Take baby, draw where top of head is with a pen on sheet or Chucx pad, and draw
where heel is, and use measuring tape from 2 points you marked on pad with pen to
get a more accurate measurement cause baby isn’t moving around
C. Head Circumference in cm
• Avg: 34.5 cm
• Sit up baby, have widest part of head.
• FOC = front occipital circumference: right above eyebrow all the way around with
tape measure
D. Chest Circumference
