NSG 3500 Unit 9 & 10 Knowledge Check
Unit 9: Newborn Assessment
Initial Assessment
Apgar Score
• Timing: Completed at 1 minute and 5 minutes after birth; repeated at 10 minutes if
score is low .
• Scoring Table :
Category 0 Points 1 Point 2 Points
Acrocyanosis (blue extremities, pink
Appearance Pale/blue Completely pink
body)
Pulse Absent <100 bpm >100 bpm
No Strong cry, prompt
Grimace Grimace, weak/slow cry
response response
Activity/ Muscle Active motion, well-
Flaccid Some flexion
tone flexed
Respiration Absent Weak, irregular Strong cry
• Normal: 7–10
• Low: 4–6
• Critical: 0–3
Vital Signs
• Temperature:
o Rectal: 98.6–100.0°F (37.0–37.8°C)
o Axillary: 97.7–99.3°F (36.5–37.4°C)
• Heart Rate: 120–160 bpm
o Sleep: as low as 80 bpm
o Crying: as high as 180 bpm
• Respiratory Rate: 30–60 breaths/min
, o Periodic breathing is normal.
o Apnea >15–20 seconds = abnormal.
• Blood Pressure: 60–80 systolic / 40–50 diastolic
Cold Stress
• Signs/Symptoms: Hypothermia (<96.6°F / 35.8°C), pallor, hypotonia, lethargy
• Causes: Heat loss > heat production
• Complications: Hypoglycemia, acidosis, respiratory distress
• Interventions: Warm environment, radiant warmer, skin-to-skin, dry and cover infant
Types of Heat Loss
Type Definition Causes Nursing Interventions
Heat lost when fluid on skin Amniotic fluid Dry thoroughly, remove wet
Evaporation
is converted to vapor not dried linens, cap on head
Heat transfer to cooler Warm blankets, preheated
Conduction Cold scale, table
surface warmer, skin-to-skin
Drafts, open
Convection Heat loss to air currents Keep room warm, swaddle
windows
Heat loss to nearby cold Cold windows, Keep crib away from cold
Radiation
surfaces walls surfaces, radiant warmers
Newborn Medications
• Eye prophylaxis: Erythromycin to prevent ophthalmia neonatorum
(gonorrhea/chlamydia).
• Vitamin K: IM injection to prevent hemorrhagic disease of newborn.
• Hepatitis B Vaccine: First dose within 12 hours if mother is HBsAg-positive.
Newborn Behavioral States
Sleep States
, 1. Deep Sleep (Quiet Sleep)
o Infant is very still, regular respirations, minimal movement.
o Eyes closed, no spontaneous activity except occasional startle.
o Difficult to arouse.
2. Light Sleep (Active Sleep/REM)
o Irregular respirations, some body movements (twitches, sucking).
o Eyes may move under lids, facial movements common.
o Infant more easily aroused compared to deep sleep.
Awake States
1. Drowsy State
o Transitional state between sleep and awake.
o Eyes may open/close, glazed appearance.
o Infant may respond slowly to stimuli.
2. Quiet Alert
o Eyes open, focused, minimal movement.
o Best state for bonding, feeding, and learning.
o Infant attentive to voices, faces, and environment.
3. Active Alert
o More movement, fussy, irregular breathing.
o Less attentive, sensitive to stimulation.
o May precede crying state.
4. Crying State
o Intense motor activity and vocalization.
o Requires comfort, feeding, or diaper change.
o Difficult to interact until needs are met
Unit 9: Newborn Assessment
Initial Assessment
Apgar Score
• Timing: Completed at 1 minute and 5 minutes after birth; repeated at 10 minutes if
score is low .
• Scoring Table :
Category 0 Points 1 Point 2 Points
Acrocyanosis (blue extremities, pink
Appearance Pale/blue Completely pink
body)
Pulse Absent <100 bpm >100 bpm
No Strong cry, prompt
Grimace Grimace, weak/slow cry
response response
Activity/ Muscle Active motion, well-
Flaccid Some flexion
tone flexed
Respiration Absent Weak, irregular Strong cry
• Normal: 7–10
• Low: 4–6
• Critical: 0–3
Vital Signs
• Temperature:
o Rectal: 98.6–100.0°F (37.0–37.8°C)
o Axillary: 97.7–99.3°F (36.5–37.4°C)
• Heart Rate: 120–160 bpm
o Sleep: as low as 80 bpm
o Crying: as high as 180 bpm
• Respiratory Rate: 30–60 breaths/min
, o Periodic breathing is normal.
o Apnea >15–20 seconds = abnormal.
• Blood Pressure: 60–80 systolic / 40–50 diastolic
Cold Stress
• Signs/Symptoms: Hypothermia (<96.6°F / 35.8°C), pallor, hypotonia, lethargy
• Causes: Heat loss > heat production
• Complications: Hypoglycemia, acidosis, respiratory distress
• Interventions: Warm environment, radiant warmer, skin-to-skin, dry and cover infant
Types of Heat Loss
Type Definition Causes Nursing Interventions
Heat lost when fluid on skin Amniotic fluid Dry thoroughly, remove wet
Evaporation
is converted to vapor not dried linens, cap on head
Heat transfer to cooler Warm blankets, preheated
Conduction Cold scale, table
surface warmer, skin-to-skin
Drafts, open
Convection Heat loss to air currents Keep room warm, swaddle
windows
Heat loss to nearby cold Cold windows, Keep crib away from cold
Radiation
surfaces walls surfaces, radiant warmers
Newborn Medications
• Eye prophylaxis: Erythromycin to prevent ophthalmia neonatorum
(gonorrhea/chlamydia).
• Vitamin K: IM injection to prevent hemorrhagic disease of newborn.
• Hepatitis B Vaccine: First dose within 12 hours if mother is HBsAg-positive.
Newborn Behavioral States
Sleep States
, 1. Deep Sleep (Quiet Sleep)
o Infant is very still, regular respirations, minimal movement.
o Eyes closed, no spontaneous activity except occasional startle.
o Difficult to arouse.
2. Light Sleep (Active Sleep/REM)
o Irregular respirations, some body movements (twitches, sucking).
o Eyes may move under lids, facial movements common.
o Infant more easily aroused compared to deep sleep.
Awake States
1. Drowsy State
o Transitional state between sleep and awake.
o Eyes may open/close, glazed appearance.
o Infant may respond slowly to stimuli.
2. Quiet Alert
o Eyes open, focused, minimal movement.
o Best state for bonding, feeding, and learning.
o Infant attentive to voices, faces, and environment.
3. Active Alert
o More movement, fussy, irregular breathing.
o Less attentive, sensitive to stimulation.
o May precede crying state.
4. Crying State
o Intense motor activity and vocalization.
o Requires comfort, feeding, or diaper change.
o Difficult to interact until needs are met
