Chart — Maternal-Newborn
Newborn Assessment Findings
A comprehensive side-by-side comparison of normal versus concerning newborn assessment findings across respiratory, cardiovascular, neurologic, and skin systems — with nursing actions for each concerning finding.
Educational use only. Neonatal assessment findings must be interpreted in clinical context. Always apply clinical judgment and follow NRP guidelines, facility protocols, and provider orders. This chart is for nursing education and NCLEX preparation. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Respiratory
| Finding | Normal | Concerning | Action |
|---|---|---|---|
| Respiratory rate | 30–60/min | >60/min (tachypnea) | Assess for distress; oxygen per NRP; notify provider |
| Breath sounds | Clear, equal bilaterally; slight coarseness immediately after birth | Absent; unequal; persistent crackles | Notify provider; assess for pneumothorax, pneumonia |
| Work of breathing | Effortless; quiet; abdominal breathing pattern normal | Grunting, nasal flaring, intercostal/subcostal retractions, seesaw respirations | NRP protocol; supplemental O2; provider STAT |
| Breathing pattern | Periodic breathing (brief pauses <10 sec) — normal in newborns | Apnea >20 sec or <20 sec with bradycardia or color change | Stimulate; PPV if not resolved; notify provider |
| Color — airway | Pink mucous membranes after stabilization | Central cyanosis (lips, mucous membranes, tongue) | Supplemental oxygen; NRP evaluation; notify provider |
Cardiovascular
| Finding | Normal | Concerning | Action |
|---|---|---|---|
| Heart rate | 110–160 bpm | <100 or >180 bpm persisting | Stimulate if bradycardic; PPV if <60; tachycardia: evaluate cause |
| Heart sounds | Regular S1 and S2; soft transient murmur in first 24–48 hrs (PDA closing) may be normal | Harsh, persistent murmur; abnormal heart sounds | Notify provider; echocardiogram evaluation |
| Pulses | Equal peripheral pulses bilaterally; capillary refill ≤3 sec | Absent/weak femoral pulses (coarctation of aorta); unequal upper/lower pulses | Notify provider; 4-extremity blood pressure comparison; echocardiogram |
| Capillary refill | ≤3 seconds (sternal or forehead) | >3 seconds; mottling persistent past transition | Assess perfusion; notify provider if persistent |
| Acrocyanosis | Blue hands and feet — normal first 24–48 hours | Persistent after warming; central cyanosis | Warm infant; reassess; evaluate O2 saturation |
Neurologic
| Finding | Normal | Concerning | Action |
|---|---|---|---|
| Tone | Flexed extremities; active resistance to extension; good muscle tone | Hypotonia (floppy); hypertonia (rigid, arched) | Notify provider; assess for birth injury, infection, metabolic cause |
| Moro reflex | Symmetric arm abduction/extension then embrace; present birth to 3–6 months | Absent; asymmetric (one arm does not respond) | Asymmetric: assess for clavicle fracture or brachial plexus injury (Erb's palsy) |
| Rooting/sucking | Strong coordinated rooting and sucking reflexes | Absent, weak, or uncoordinated suck (poor feeding) | Evaluate for sepsis, CNS injury, metabolic disorder; consult lactation if latch issue |
| Cry | Strong, lusty cry with stimulation | High-pitched, shrill cry (CNS insult); weak or absent cry | Notify provider; assess glucose, sepsis screen, neurologic evaluation |
| Jitteriness / Seizures | Occasional startle — benign; stops with holding | Persistent jitteriness not stopped by holding; repetitive tonic-clonic movements | Check glucose STAT; notify provider; antiepileptic per order if seizure confirmed |
Skin Findings
| Finding | Normal | Concerning | Action |
|---|---|---|---|
| Jaundice | Physiologic: appears after 24 hrs; peaks days 3–5; resolves by 2 weeks | Jaundice within first 24 hours (always pathologic); severe jaundice at any time | Transcutaneous bilirubin; total serum bilirubin; phototherapy per threshold; treat underlying cause |
| Milia | White pinpoint papules on nose and chin — blocked sebaceous glands; resolves spontaneously | N/A — benign; do not squeeze | Reassure parents; no treatment needed |
| Erythema toxicum | Red blotchy rash with white/yellow papules; days 1–2; benign, resolves spontaneously | Vesicular rash (may be HSV); pustules with surrounding erythema (infection) | Vesicular lesions: notify provider; culture lesion; rule out HSV |
| Mongolian spots | Blue-gray pigmentation, lumbosacral area; benign; common in darker-skinned neonates | Must document at birth to distinguish from bruising/abuse | Document location, size, color in birth record; inform parents |
| Caput succedaneum | Scalp edema crossing suture lines; soft; resolves days 1–3 | Cephalohematoma does NOT cross suture lines; firmer; associated with jaundice risk | Monitor bilirubin with cephalohematoma; educate parents; no treatment for caput |
NCLEX Pearls
- Jaundice in the first 24 hours is ALWAYS pathologic — requires immediate bilirubin measurement
- Caput crosses suture lines; cephalohematoma does NOT — the most commonly tested distinction
- Grunting in a newborn is ominous — it indicates the infant is trying to maintain FRC and is in respiratory distress
- Acrocyanosis (blue hands/feet) is normal; central cyanosis (blue lips/tongue) is never normal
- Absent femoral pulses suggest coarctation of the aorta — notify provider
- Jitteriness that stops when held = normal startles; jitteriness that persists with holding = assess glucose
- Mongolian spots must be documented at birth to protect against false abuse allegations
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with NRP / AAP Neonatal Assessment Standards. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →