Newborn nursing care: APGAR scoring, thermoregulation, and early jaundice detection

Newborn nursing care in the first hours and days of life sets the foundation for every healthy outcome that follows. As a nurse on a mother-baby unit, labor and delivery floor, or newborn nursery, you are responsible for a systematic set of assessments and interventions that must happen in a specific sequence and within precise time windows. This guide covers the full scope of routine care for the healthy term newborn: initial assessment and APGAR scoring, thermoregulation, immediate post-birth medications, umbilical cord care, newborn screening, feeding support, jaundice monitoring, safe sleep, and the common normal findings that nursing students routinely misidentify as pathology. NCLEX tests this content heavily – particularly medication routes, jaundice timing, and safe sleep positioning.

Quick-reference: immediate newborn interventions

Thermoregulation

Newborns are at high risk for hypothermia. A term infant’s surface area to body mass ratio is much larger than an adult’s, their skin is thin and poorly insulating, and their ability to shiver is absent. The primary thermogenic mechanism in newborns is non-shivering thermogenesis, driven by brown adipose tissue (BAT). BAT is metabolically active fat concentrated around the neck, mediastinum, adrenal glands, and kidneys. When stimulated by cold, BAT generates heat through uncoupled oxidative metabolism rather than muscle contraction.

Four mechanisms of heat loss

Cold stress consequences

When a newborn’s core temperature drops, BAT is mobilized and oxygen consumption increases. In cold stress, the infant consumes more oxygen to generate heat, which can deplete glucose stores rapidly, leading to hypoglycemia. Cold stress is a clinical spiral: hypothermia → increased oxygen consumption → hypoglycemia → metabolic acidosis → worsened vasoconstriction and pulmonary vascular resistance.

Normal axillary temperature for a term newborn: 36.5–37.5°C (97.7–99.5°F).

Choosing the route: Routine temperature checks in the newborn nursery are taken in the axilla. Axillary readings approximate core temperature closely enough in healthy term newborns to work as a screen, and the route avoids the small risk of rectal injury that led nurseries to drop routine rectal checks. Rectal temperature is still the most accurate method in infants under 3 months, and it is the reference standard for confirming fever: the AAP febrile infant guideline is built on a rectal temperature of 38.0°C (100.4°F) or higher, and many units check a rectal reading when an axillary value is borderline or questioned. Rectal perforation from a thermometer is rare, and the reported cases occurred in hospital nurseries, mostly in the era of glass thermometers. When a rectal reading is needed, use a digital thermometer, insert it no more than 1/2 inch (about 1.25 cm) in infants under 6 months, and stop at any resistance. Use the axillary route instead in infants with necrotizing enterocolitis, a bleeding disorder, or neutropenia. Fever cutoffs differ by site (axillary 37.2°C/99.0°F, rectal 38.0°C/100.4°F) – see vital signs by age.

Neutral thermal environment

A neutral thermal environment (NTE) is the ambient temperature range in which the infant can maintain normal body temperature with the least metabolic effort. For term infants under a radiant warmer, the NTE is approximately 34–35°C at birth. For infants in incubators, the NTE is set based on gestational age and weight using standardized charts.

Warming interventions

• Skin-to-skin (kangaroo care): Most effective non-equipment warming. Place naked infant prone on parent’s bare chest, covered with warm blanket. Stabilizes temperature, promotes breastfeeding, reduces stress hormones.
• Radiant warmer: Use immediately post-delivery. Infrared heat source above the infant. Can lead to insensible water loss – monitor for dehydration with prolonged use.
• Warm blankets and cap: Simple and effective. A significant proportion of heat loss in newborns occurs through the head.
• Delayed bath: The first bath should be deferred at least 6 hours (ideally 12–24 hours) after birth. Early bathing causes rapid evaporative heat loss.

Immediate post-birth interventions

Vitamin K (phytonadione)

Newborns are born with low levels of vitamin K. The gut flora responsible for producing vitamin K are not yet established, and breast milk contains only small amounts. Without sufficient vitamin K, clotting factors II, VII, IX, and X are inadequately activated, placing the infant at risk for vitamin K deficiency bleeding (VKDB), previously called hemorrhagic disease of the newborn.

VKDB can be early (first 24 hours), classic (days 1–7), or late (2–12 weeks). Late VKDB carries the highest risk of intracranial hemorrhage.

Administration:

• Drug: Phytonadione (vitamin K1)
• Dose (AAP 2022 policy): a single 1 mg IM dose for infants weighing more than 1,500 g; 0.3–0.5 mg/kg IM for preterm infants weighing 1,500 g or less
• Route: IM only – not IV, not oral (oral forms are not FDA-approved in the US and provide inconsistent protection)
• Site: Vastus lateralis (anterolateral thigh) – this is the preferred site for all IM injections in newborns, not the deltoid
• Timing: Within 6 hours of birth; typically given in the delivery room after initial stabilization and the first skin-to-skin period

NCLEX alert: The route is IM, not IV. The site is the vastus lateralis, not the deltoid. If a parent refuses vitamin K, document the refusal thoroughly and ensure the provider counsels the family on VKDB risk.

Erythromycin eye ointment

Purpose: Prophylaxis against gonococcal ophthalmia neonatorum – a conjunctivitis caused by Neisseria gonorrhoeae acquired during passage through the birth canal, which can cause rapid corneal damage and blindness within 48 hours if untreated.

Important scope limit: erythromycin is the only ocular prophylaxis agent available in the US, and per CDC STI treatment guidance it is not effective against Chlamydia trachomatis. Ocular prophylaxis does not prevent chlamydial conjunctivitis or chlamydial pneumonia. Prevention of neonatal chlamydia depends on prenatal screening and treatment of the pregnant patient, not on the eye ointment.

Administration:

• Drug: Erythromycin ophthalmic ointment 0.5%
• Application: Apply a 1 cm ribbon of ointment to the lower conjunctival sac of each eye
• Timing: Within 1–2 hours of birth (may be delayed briefly to allow parent-infant bonding immediately post-delivery)
• Technique: Wipe excess ointment from outer canthus; do not irrigate or wipe off the ointment – it needs to remain in contact with the conjunctiva
• Expected finding: Transient blurred vision and mild conjunctival irritation immediately after application – this is normal

Note: Erythromycin does not prevent all causes of neonatal conjunctivitis. Chemical conjunctivitis (from the ointment itself) can occur within the first 24–48 hours and resolves spontaneously.

Hepatitis B vaccine (first dose)

• Dose: 0.5 mL IM
• Site: Anterolateral thigh (vastus lateralis)
• Timing: Within 24 hours of birth for medically stable infants weighing at least 2,000 g born to HBsAg-negative mothers (infants under 2,000 g in this group receive dose 1 at 1 month or at hospital discharge); within 12 hours of birth, together with HBIG, for infants born to HBsAg-positive mothers. If the mother’s status is unknown, give the vaccine within 12 hours and test the mother; HBIG follows if she tests positive (infants under 2,000 g receive HBIG within 12 hours if her status cannot be determined by then)
• Series: Three-dose series (birth, 1–2 months, 6–18 months)

Current policy note: Federal guidance on the birth dose has been in flux. In December 2025 the CDC adopted an ACIP vote moving the birth dose for infants of HBsAg-negative mothers to individual decision-making. A federal court stayed that change in March 2026 while an appeal proceeds, and the AAP continues to recommend the universal birth dose within 24 hours. Recommendations for infants of HBsAg-positive or unknown-status mothers were not changed. Follow your facility’s current protocol.

Newborn physical assessment

The newborn physical exam follows a head-to-toe sequence. Normal values and common benign findings must be distinguished from pathologic ones – NCLEX frequently presents normal newborn findings as traps.

Normal newborn vital signs (term infant):

• Heart rate: 110–160 bpm at rest (runs lower in deep sleep and higher with crying; the AHA PALS neonatal ranges are 90–160 bpm asleep and 100–205 bpm awake – see vital signs by age)
• Respiratory rate: 30–60 breaths/minute
• Axillary temperature: 36.5–37.5°C
• Blood pressure: 60–80 / 40–50 mmHg
• SpO₂: ≥95% after 10 minutes of age (refer to Kamlin/Dawson normative data for first-minute values)

Head-to-toe assessment highlights

Head: Assess fontanelles – anterior fontanelle is diamond-shaped, soft and flat when infant is quiet and upright. Bulging fontanelle suggests increased intracranial pressure; sunken fontanelle suggests dehydration. Posterior fontanelle is triangular and may close within 6–8 weeks.

Eyes: Symmetric, equal pupil response. Subconjunctival hemorrhages (red patches on the sclera) are common after vaginal delivery and resolve in 1–2 weeks – benign, no intervention needed.

Ears: Pinna recoils immediately when folded – indicates gestational maturity. Low-set ears may indicate chromosomal abnormalities.

Mouth: Assess for cleft lip and palate by inspection and palpation of hard palate. Epstein pearls (tiny white cysts on the hard palate or gum margins) are normal epithelial inclusion cysts – they resolve spontaneously.

Chest: Breast engorgement and witch’s milk (small amount of milky discharge) may occur in both male and female infants due to maternal estrogen – normal and self-resolving. Respiratory rate should be counted for a full 60 seconds. Grunting, flaring, and retractions indicate respiratory distress.

Abdomen: Soft and rounded. Bowel sounds present within 1–2 hours. Assess umbilical cord – should have two arteries and one vein (AVA: one vein, two arteries). A single umbilical artery may indicate renal or cardiac anomalies.

Genitalia: In females, a small amount of blood-tinged vaginal discharge (pseudomenstruation) from maternal estrogen withdrawal is normal in the first week. In males, assess testes are descended bilaterally.

Hips: Ortolani (abduction) and Barlow (adduction) maneuvers screen for developmental dysplasia of the hip (DDH). A clunk (not click) is abnormal and warrants orthopedic referral.

Spine: Assess for sacral dimple with a tuft of hair (may indicate spina bifida occulta) vs simple dimple above the gluteal cleft (benign).

Skin: See the common findings section below.

Neurological/reflexes: Assess primitive reflexes to confirm neurological integrity.

Umbilical cord care

The umbilical cord stump should be kept clean and dry. Current evidence-based practice (AAP recommendation) supports the dry natural method – no alcohol, no antiseptics, no covering.

• Expected separation: 7–14 days after birth (range 5–15 days)
• Care instructions: Keep dry; fold the front of the diaper down to avoid covering the cord; sponge-bath only until the cord falls off (no tub baths)
• What is normal: The cord dries, shrivels, turns from yellow-green to brown-black, and falls off. A small amount of dried blood at the base during separation is expected.

Signs of omphalitis (infection – requires immediate intervention)

Omphalitis is a bacterial infection of the umbilical stump and surrounding skin. It is uncommon but serious.

Signs: Redness, warmth, and swelling of the periumbilical skin (not just the cord itself), foul odor, purulent drainage at the base. Fever may or may not be present.

Management: Omphalitis requires prompt antibiotic therapy – this is not a home-care finding. Educate parents clearly: redness of the skin around the base (not just the cord tip turning dark) is the key distinguishing sign.

Parent education points:

• Do not pull the cord stump off – let it separate naturally
• Sponge baths only until 1–2 weeks after cord falls off (navel heals)
• Notify provider if: redness at the skin base, foul smell, persistent moisture, bleeding beyond a small amount

Newborn screening

Newborn screening identifies conditions that are treatable when caught early but cause severe harm if missed. Screening is mandatory in all US states; the specific panel varies by state but all states screen for the core conditions listed below.

Timing: Blood specimen collected by heel stick to a Guthrie filter paper card at 24–72 hours of age. Collection before 24 hours may yield false-negative results for PKU because phenylalanine has not yet accumulated.

Heel stick technique: Warm the heel for 3–5 minutes to increase blood flow. Use the lateral plantar surface – never the posterior curve or central plantar surface (risk of bone injury). Lance, allow blood to drip, fill all required circles on the card without smearing.

Core conditions screened (RUSP uniform panel)

A positive (abnormal) screen is not a diagnosis – it triggers confirmatory testing. Educate parents that a callback does not mean their infant is confirmed to have a condition.

Hearing screen

Two technologies are used:

• Automated auditory brainstem response (AABR): Places electrodes on the scalp; measures brainstem’s response to sound. Can detect auditory neuropathy.
• Otoacoustic emissions (OAE): A small probe in the ear canal emits sounds and detects the echo produced by the cochlea. Faster but cannot detect auditory neuropathy.

A “refer” result (did not pass) triggers outpatient diagnostic follow-up. The JCIH benchmark is the 1-3-6 rule: hearing screening completed by 1 month of age, diagnostic audiologic and medical evaluation completed by 3 months if the infant does not pass, and enrollment in early intervention services by 6 months. Meeting all three benchmarks is what drives the language and literacy outcomes; delay at any stage erodes them.

CCHD pulse oximetry screen

Screens for critical congenital heart defects that may not be detectable on physical exam alone. Performed at ≥24 hours of age or as late as possible before discharge.

Technique: Measure SpO₂ simultaneously on the right hand (preductal) and either foot (postductal).

Current algorithm (Martin et al. 2020, endorsed by the AAP and reaffirmed in the 2025 AAP clinical report):

• Pass: SpO₂ ≥95% in both the hand and the foot, and the difference between them is ≤3%.
• Fail (refer immediately): SpO₂ <90% in either extremity at any point.
• Repeat once in 1 hour: SpO₂ 90–94% in either extremity, or a hand-foot difference >3%. If the repeat screen does not pass, the screen fails.

The 2020 algorithm replaced the 2011 version in two ways students are often taught wrongly: the ≥95% threshold must now be met in both extremities (formerly either), and only one repeat screen is allowed (formerly two). The difference criterion is >3%, not ≥4%.

Feeding assessment and support

Breastfeeding

Breastfeeding should begin within the first hour of life, ideally during the initial skin-to-skin period when the rooting reflex is strong. Early and frequent feeding establishes milk supply and reduces jaundice risk by promoting gut motility.

Expected feeding frequency: 8–12 feedings per 24 hours (every 2–3 hours). Feed on demand – do not clock-feed. Cluster feeding in the evening is normal and does not indicate insufficient milk.

Latch assessment – signs of a good latch:

• Wide mouth, with lips flanged outward (lower lip especially)
• Chin touching the breast, nose clear of the breast (not pressed in)
• Asymmetric latch – more areola visible above the nipple than below
• Audible swallowing after the first few sucks
• No pain for the mother beyond initial seconds of latch

Assessing adequate intake – diaper output is the primary indicator:

Normal weight loss: Up to 7–10% of birth weight in the first 3–5 days is normal. Regain should occur by 10–14 days of life. Weight loss >10% warrants evaluation of feeding adequacy and possible supplementation.

Colostrum vs mature milk: Colostrum (days 1–3) is thick, yellowish, and rich in immunoglobulins – particularly secretory IgA. The infant receives small volumes (5–7 mL per feeding) – this is adequate for the stomach capacity of a term newborn. Mature milk transitions in by days 3–5.

Formula feeding

• Standard term formula: 20 kcal/oz
• Typical intake: 2–3 oz every 3–4 hours in the first weeks, increasing to 4 oz by 1 month
• Sterile water preparation (if using powder): use water that has been boiled and cooled, or commercially sterile bottled water labeled for infant use
• Ready-to-feed formula requires no preparation – preferred for hospitalized newborns
• Burping: Pause mid-feeding and after feeding. Position upright or prone over shoulder and pat/rub back. Some infants need burping every 1–2 oz; others less frequently.

Jaundice monitoring

Neonatal jaundice (hyperbilirubinemia) is the most common condition requiring medical evaluation in newborns, affecting approximately 60% of term and 80% of preterm infants in the first week.

Physiologic vs pathologic jaundice

The distinction is almost entirely timing-based:

Physiologic jaundice:

• Appears after 24 hours of age (day 2–3)
• Peaks at day 3–5 (total bilirubin typically <12–15 mg/dL in term infants)
• Resolves by day 7–10 in term infants (longer in preterm)
• Cause: high red blood cell turnover + immature hepatic conjugation capacity + enterohepatic recirculation

Pathologic jaundice:

• Appears in the first 24 hours – this is the hallmark finding
• Rises rapidly (>5 mg/dL/day)
• May exceed thresholds requiring phototherapy or exchange transfusion
• Causes include hemolytic disease (ABO incompatibility, Rh incompatibility), G6PD deficiency, sepsis, biliary atresia

Key NCLEX rule: Jaundice in the first 24 hours of life is ALWAYS pathologic until proven otherwise.

Bilirubin assessment methods

• Transcutaneous bilirubinometry (TcB): Non-invasive device pressed against skin (typically sternum or forehead). Screens for jaundice and guides whether serum testing is needed. Not accurate after phototherapy has started.
• Total serum bilirubin (TSB): Heel stick or venipuncture. Plotted against the infant’s age in hours to determine the phototherapy threshold.

Phototherapy thresholds are individualized based on age in hours, gestational age, and neurotoxicity risk factors – there is no single cutoff number. Use the curves from the 2022 AAP clinical practice guideline revision, which replaced the 2004 guideline. Two changes matter at the bedside: the 2022 thresholds are somewhat higher than the 2004 ones (reflecting evidence on the safety of slightly higher bilirubin levels and the harms of overtreatment), and the guideline provides separate curves for each gestational age from 35 weeks upward, split by presence or absence of neurotoxicity risk factors. The older Bhutani risk-zone nomogram is still used in some institutions for predischarge risk stratification, but it does not set the 2022 treatment thresholds.

Phototherapy nursing care

Phototherapy uses blue-green wavelength light to isomerize unconjugated bilirubin in the skin into water-soluble forms that can be excreted without hepatic conjugation.

Nursing responsibilities during phototherapy:

• Apply eye shields (photomask) before placing under lights – retinal damage is a risk
• Maximize skin exposure: remove clothes and diaper (cover genitals with smallest possible diaper)
• Position infant close to light source per manufacturer guidelines; fiber-optic biliblankets can be used for lower-level jaundice
• Monitor temperature closely – lights generate heat; hypothermia and hyperthermia are both possible depending on setup
• Encourage frequent feeding (8–12 times/24 hours) – breast milk promotes gut motility and reduces enterohepatic reabsorption
• Monitor for loose green stools (expected – bilirubin excretion through gut)
• Remove eye shields during feedings to promote visual stimulation and bonding
• Check bilirubin levels per orders – typically every 4–12 hours depending on trajectory
• Do NOT apply sunscreen or lotions – they can cause skin burns under phototherapy lights

Bronze baby syndrome: If an infant with cholestatic (conjugated) jaundice undergoes phototherapy, the skin, urine, and serum may turn a grayish-brown color. Phototherapy is not effective for conjugated hyperbilirubinemia – it is contraindicated in this context.

Safe sleep (AAP guidelines)

Sudden unexpected infant death (SUID), which includes SIDS, is the leading cause of post-neonatal mortality in the US. The AAP publishes evidence-based safe sleep guidelines that nurses are responsible for teaching at every clinical encounter.

Core AAP safe sleep recommendations:

• Supine position (on the back) for every sleep until age 1 year – no exceptions for “tummy time” during sleep
• Firm, flat, non-inclined sleep surface – approved crib, bassinet, or play yard mattress with a fitted sheet only. The 2022 policy added an explicit non-inclined requirement (a sleep surface inclined more than 10 degrees is not safe)
• No bed-sharing – sharing a sleep surface with parents, siblings, or any other person increases SUID risk. Room-sharing without bed-sharing is recommended, ideally for the first 6 months (the 2022 policy shortened this from the 2016 “at least 6 months, ideally 1 year,” because roughly 90% of sleep-related deaths occur in the first 6 months)
• No loose bedding – no blankets, pillows, bumpers, positioners, or stuffed animals in the sleep space
• Pacifier at sleep time: associated with reduced SUID risk. Offer after breastfeeding is established (approximately 3–4 weeks); do not force; do not reinsert if it falls out during sleep
• Avoid overheating: dress infant in one additional layer vs an adult in the same room; do not swaddle too tight or use sleep sacks that restrict leg movement

Nursing teaching points:

• Tummy time is recommended during supervised awake periods to promote motor development and prevent positional plagiocephaly – but only when the infant is awake and someone is watching
• Swaddling before the infant can roll over is acceptable but should stop once the infant shows signs of rolling
• Never leave a newborn sleeping in a car seat, swing, bouncy seat, or other non-flat device for an extended period (inclined devices risk positional asphyxia)

Circumcision care

When circumcision is performed (typically within the first 1–2 days of life), the nursing care focuses on bleeding monitoring, infection prevention, and pain management.

Immediate post-procedure care:

• Apply petroleum jelly gauze (Vaseline gauze) with each diaper change for the first 24–48 hours to prevent the healing glans from adhering to the diaper
• Check for bleeding with each diaper change – a small amount of bloody spotting is normal; a dime-sized or larger spot, or active dripping, requires immediate provider notification
• Observe for first voiding post-circumcision – should occur within 6–8 hours

Normal healing findings:

• A yellowish-white exudate forms over the glans within 24 hours and persists for several days – this is granulation tissue (fibrin), not infection/pus
• Slight swelling and redness at the surgical site is expected
• Full healing takes 7–10 days

Signs of infection (escalate): Increasing redness and warmth extending beyond the glans onto the shaft, purulent (green/foul) discharge, fever, swelling that worsens after day 2–3.

Pain management: Sucrose pacifier (24% oral sucrose solution) and acetaminophen per protocol. Assess pain with a validated neonatal pain scale (NIPS or FLACC).

Common newborn findings – normal vs concerning

Primitive reflexes (normal newborn)

• Moro reflex (startle): Extension then flexion of arms in response to sudden movement or loud noise. Present at birth; disappears by 4–6 months. Absent Moro suggests neurological injury.
• Rooting reflex: Infant turns head toward stimulation of cheek or corner of mouth. Facilitates breastfeeding. Disappears ~4 months.
• Sucking reflex: Strong rhythmic sucking when the palate is stimulated. Present at 32+ weeks gestation.
• Palmar grasp: Fingers curl around object placed in palm. Disappears ~5–6 months.
• Plantar grasp: Toes curl when sole is pressed near toes. Disappears ~9–12 months.
• Babinski reflex: Toes fan out and big toe dorsiflexes when sole is stroked heel-to-toe. Normal in infants; pathologic if present after 2 years of age (indicates upper motor neuron lesion).
• Stepping reflex: Infant makes stepping movements when held upright with feet touching surface. Disappears ~2 months.

NCLEX tips

1. Vitamin K is given IM, not IV. The site is the vastus lateralis (anterolateral thigh), not the deltoid.
2. Erythromycin eye ointment prevents gonococcal ophthalmia neonatorum from N. gonorrhoeae only. It is not effective against C. trachomatis – chlamydial conjunctivitis and chlamydial pneumonia are prevented by prenatal screening and treatment of the pregnant patient, not by the eye ointment (CDC STI Treatment Guidelines, 2021).
3. Do not irrigate or wipe off erythromycin ointment after application – it must remain in contact with the conjunctiva.
4. Jaundice appearing in the first 24 hours is pathologic – always escalate.
5. Physiologic jaundice appears after 24 hours (day 2–3) and peaks day 3–5. It is not present at birth.
6. The four mechanisms of heat loss are evaporation, conduction, convection, and radiation. Know a clinical example and nursing intervention for each.
7. Newborns cannot shiver. Their thermogenic mechanism is brown adipose tissue (BAT) non-shivering thermogenesis.
8. Normal axillary temperature is 36.5–37.5°C. Axillary is the routine route in the newborn nursery; rectal is the most accurate route in infants under 3 months and is used to confirm a suspected fever. A rectal temperature of 38.0°C (100.4°F) or higher in an infant this young requires immediate provider notification. If a question asks for the most accurate method in a young infant, the answer is rectal.
9. Cord care is dry – no alcohol. Alcohol is the old practice and is no longer recommended.
10. Omphalitis is redness of the periumbilical skin (not just the cord stump). It requires antibiotic treatment.
11. Newborn screening heel stick should occur at 24–72 hours – before 24 hours causes false-negative PKU results because phenylalanine hasn’t accumulated yet.
12. Safe sleep: supine only, firm flat surface, no bed-sharing, no loose bedding. These four points appear on the NCLEX repeatedly.
13. A pacifier at sleep reduces SUID risk – but offer it after breastfeeding is established.
14. Caput succedaneum crosses suture lines and is present at birth. Cephalohematoma does not cross suture lines and appears hours after birth.
15. Congenital dermal melanocytosis (the current term for what older sources call “Mongolian spots”) must be documented in the medical record to prevent future misidentification as bruising, especially in child welfare contexts.
16. Yellow exudate after circumcision is normal granulation tissue – not infection. Purulent discharge extending onto the shaft with worsening swelling is infection.
17. Normal newborn weight loss is up to 7–10% of birth weight. Loss >10% requires evaluation.
18. Breastfed newborns should feed 8–12 times per 24 hours. Fewer than 8 feedings per day is inadequate.
19. The Babinski reflex (toe fanning) is normal in infants and pathologic after age 2 – a common NCLEX distractor.
20. CCHD pulse oximetry screen uses the right hand (preductal) and one foot (postductal). Under the current 2020 algorithm, passing requires SpO₂ ≥95% in both sites with a difference of ≤3%; older sources teaching “either extremity” and a ≥4% difference reflect the superseded 2011 algorithm.

Related resources

• APGAR score: what it measures and how nursing students use it – Comprehensive guide to the 5-criterion scoring tool used at 1 and 5 minutes
• Neonatal nursing reference: NICU care, assessment, and common conditions – NICU-focused care, Ballard score, RDS, NEC, and neonatal pathophysiology
• Postpartum nursing care – Maternal assessment and care in the immediate postpartum period
• Vital signs by age – Normal vital sign ranges from newborn through adult

References

1. Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, et al. Clinical practice guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859
2. Moon RY, Carlin RF, Hand I; Task Force on Sudden Infant Death Syndrome. Sleep-related infant deaths: updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022;150(1):e2022057990. doi:10.1542/peds.2022-057990
3. Moon RY, Carlin RF, Hand I; Task Force on Sudden Infant Death Syndrome. Evidence base for 2022 updated recommendations for a safe infant sleeping environment to reduce the risk of sleep-related infant deaths. Pediatrics. 2022;150(1):e2022057991. doi:10.1542/peds.2022-057991
4. Martin GR, Ewer AK, Gaviglio A, Hom LA, Saarinen A, et al. Updated strategies for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2020;146(1):e20191650. doi:10.1542/peds.2019-1650
5. Oster ME, Pinto NM, Pramanik AK, Markowsky A, Schwartz BN, et al. Newborn screening for critical congenital heart disease: a new algorithm and other updated recommendations: clinical report. Pediatrics. 2025;155(1):e2024069667. doi:10.1542/peds.2024-069667
6. Kemper AR, Mahle WT, Martin GR, Cooley WC, Kumar P, et al. Strategies for implementing screening for critical congenital heart disease. Pediatrics. 2011;128(5):e1259–e1267. doi:10.1542/peds.2011-1317
7. Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1–187. doi:10.15585/mmwr.rr7004a1
8. Hand I, Noble L, Abrams SA; Committee on Fetus and Newborn, Section on Breastfeeding, Committee on Nutrition. Vitamin K and the newborn infant. Pediatrics. 2022;149(3):e2021056036. doi:10.1542/peds.2021-056036
9. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103(1):6–14. doi:10.1542/peds.103.1.6
10. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;(11):CD003519. doi:10.1002/14651858.CD003519.pub4
11. McCall EM, Alderdice F, Halliday HL, Vohra S, Johnston L. Interventions to prevent hypothermia at birth in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2018;(2):CD004210. doi:10.1002/14651858.CD004210.pub5
12. Imdad A, Bautista RMM, Senen KAA, Uy MEV, Mantaring JB III, et al. Umbilical cord antiseptics for preventing sepsis and death among newborns. Cochrane Database Syst Rev. 2013;(5):CD008635. doi:10.1002/14651858.CD008635.pub2
13. Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988
14. American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn. Elimination of perinatal hepatitis B: providing the first vaccine dose within 24 hours of birth. Pediatrics. 2017;140(3):e20171870. doi:10.1542/peds.2017-1870
15. Joint Committee on Infant Hearing. Year 2019 position statement: principles and guidelines for early hearing detection and intervention programs. J Early Hear Detect Interv. 2019;4(2):1–44.
16. American College of Obstetricians and Gynecologists. Committee Opinion No. 814: delayed umbilical cord clamping after birth. Obstet Gynecol. 2020;136(6):e100–e106. doi:10.1097/AOG.0000000000004167
17. Polin RA, Carlo WA; Committee on Fetus and Newborn. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics. 2014;133(1):156–163. doi:10.1542/peds.2013-3443
18. Blackburn ST. Maternal, Fetal, and Neonatal Physiology: A Clinical Perspective. 5th ed. St. Louis: Elsevier; 2018.
19. Cunningham FG, Leveno KJ, Dashe JS, et al. Williams Obstetrics. 26th ed. New York: McGraw-Hill Education; 2022.
20. World Health Organization. WHO Recommendations on Newborn Health: Guidelines Approved by the WHO Guidelines Review Committee. Geneva: WHO; 2017.
21. Pantell RH, Roberts KB, Adams WG, Dreyer BP, Kuppermann N, et al. Evaluation and management of well-appearing febrile infants 8 to 60 days old. Pediatrics. 2021;148(2):e2021052228. doi:10.1542/peds.2021-052228
22. Friedrichs J, Staffileno BA, Fogg L, et al. Axillary temperatures in full-term newborn infants: using evidence to guide safe and effective practice. Adv Neonatal Care. 2013;13(5):361–368. doi:10.1097/ANC.0b013e3182a14f5a
23. American Academy of Pediatrics. How to take a child’s temperature. HealthyChildren.org. Updated April 17, 2024.
24. Massaro K, Schmitt BD. Rectal thermometry to confirm fever in babies under 3 months: the evidence behind the practice. Schmitt-Thompson Clinical Content, Clinical Update for Telephone Triage Nurses; March 2018.
25. Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, et al. Prevention of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67(1):1–31. doi:10.15585/mmwr.rr6701a1