Once the newborn has taken their first breaths and stabilized, the next task is a comprehensive assessment: gestational age, physical wellbeing, and the subtle cues that reveal whether the transition to life outside the womb is progressing smoothly. Newborn assessment requires distinguishing what is normal, what is concerning, and what is an early warning sign of pathology.

On the NCLEX, newborn assessment questions test your ability to discriminate normal transitional findings from red-flag abnormalities.

Learning objectives

By the end of this section, you should be able to:

Perform a complete newborn head-to-toe assessment, including skin, head, respiratory, cardiac, abdominal, musculoskeletal, and neurological domains.
Distinguish normal transitional findings from abnormal or pathological findings.
Recognize early signs of sepsis, respiratory distress, birth trauma, and congenital abnormalities.
Interpret common newborn reflexes and understand their developmental significance.
Identify normal elimination patterns and indicators of dehydration or GI/GU obstruction.
Assess gestational age using standardized tools (Ballard exam).

Newborn measurements (baseline)

These measurements give the first clues about growth, gestational age, and potential complications.

Weight: 2500-4000 g (5.5-8.8 lbs)
- Weight loss up to 10% in the first week is normal
Length: 18-22 in (45-55 cm)
Head circumference: 32-36.8 cm
Chest circumference: 30-33 cm
Temperature: 36.5-37.5°C
HR: 110-160 bpm
RR: 30-60/min

General appearance

Normal transitional findings include:

Flexed posture
Strong cry
Pink coloring with possible acrocyanosis
Lanugo (fine hair) on shoulders/back
Vernix caseosa (white creamy coating)

Abnormal:

Limp or hypotonic posture
Weak or high-pitched cry (neurologic concern)
Pallor or central cyanosis
Flaccidity
Poor weight or abnormal proportions

A two-panel comparison of newborn tone and appearance: the normal panel shows the hip, knee, and elbow flexed at roughly 90 degrees, with skin tone swatches for pink coloring with acrocyanotic hands/feet, vernix in skin folds, and lanugo on the shoulders; the atypical panel shows the same joints extended to roughly 180 degrees (reduced resting joint angle indicating hypotonia) alongside a pale/dusky circumoral skin swatch. A legend at the bottom explains the skin tone, vernix, lanugo, and joint-angle icons. — Normal vs abnormal general appearance of a newborn

Skin assessment

Normal findings

Vernix: white, creamy protective coating
Lanugo: fine hair, more common in premature infants
Milia: tiny white sebaceous cysts
Erythema toxicum: newborn rash, benign
Mongolian spots: blue-gray patches often on sacrum/buttocks
Peeling skin after 24 hours is normal

A six-panel grid of numbered newborn skin findings: (1) Vernix caseosa, a white creamy coating in a skin crease and as a close-up texture; (2) Lanugo, fine soft hair strands; (3) Milia, tiny white bumps on skin viewed through a magnifying glass; (4) Erythema toxicum, a blotchy red rash with small pale central bumps; (5) Mongolian spot, a flat blue-gray patch of skin; (6) Physiologic peeling, dry cracked and flaking skin texture. A green banner beneath states these are common, expected newborn skin findings. — Normal newborn skin findings

Abnormal findings

Jaundice within first 24 hours (pathologic)
Petechiae, purpura
Large hemangiomas
Cyanosis of lips/tongue
Pallor (may indicate anemia, shock, sepsis)

A six-panel grid of newborn skin findings, each panel labeled with a numbered blue header: (1) Jaundice shows a yellow-tinged infant face and yellow sclera; (2) Petechiae shows numerous small pinpoint red-purple spots across an infant's back; (3) Purpura shows larger purplish-blue bruised patches on an infant's upper arm; (4) Hemangioma shows a raised, bumpy strawberry-red lesion on an infant's cheek; (5) Central Cyanosis shows a close-up of an infant's blue-tinged lips and tongue; (6) Pallor shows an infant's face with pale, washed-out skin tone. — Abnormal newborn skin findings requiring further evaluation

Head assessment

Fontanelles

Anterior fontanelle: diamond-shaped, closes by 12-18 months
Posterior fontanelle: triangular, closes by 2-3 months

Normal: soft, flat.

Abnormal:

Bulging (↑ ICP, infection)
Sunken (dehydration)

Two illustrations of an infant skull showing fontanelle locations. The top-view diagram shows a diamond-shaped anterior fontanelle at the front of the head and a smaller triangular posterior fontanelle at the back, both along the cranial suture lines. The side-view illustration of a baby's head confirms the anterior fontanelle near the forehead/top of the skull and the posterior fontanelle toward the back of the head. — Anterior and posterior fontanelles

Caput succedaneum vs cephalohematoma

Caput succedaneum
- Crosses suture lines
- Soft, boggy swelling from birth trauma
- Resolves in 24-48 hours
Cephalohematoma
- Does not cross suture lines
- Blood between skull bone & periosteum
- Risk for jaundice

Side-by-side cross-sections of a newborn scalp and skull. Left panel, Caput succedaneum: diffuse soft swelling in the scalp layer that extends across the suture line, with the skull, brain, and suture line labeled. Right panel, Cephalohematoma: a localized pocket of blood confined to one side of the head, stopping at the suture line, with scalp, skull, brain, and suture line labeled. — Caput succedaneum vs cephalohematoma

Eyes, ears, nose, throat (EENT)

Eyes

Normal:

Symmetrical placement
Pupillary reflex present
Red reflex present

Abnormal:

Absent red reflex (retinoblastoma, cataracts)
Persistent drainage (blocked tear duct)
Subconjunctival hemorrhages can be normal from birth pressure

Ears

Normal:

Alignment with outer canthus of eye
Well-formed pinna

Abnormal:

Low-set ears → genetic syndromes (Trisomy 21)
Ear tags/pits may require renal investigation

Nose & mouth

Normal:

Obligate nose breather
Rooting reflex
Sucking reflex
Palate intact

Abnormal:

Cleft lip/palate
Choanal atresia (cyanosis relieved by crying)
Asymmetric cry (possible nerve injury)
White plaques that scrape off = milk; do not scrape off = thrush

Chest & lungs

Normal

Symmetrical movement
Breathing irregular
Fine crackles first hours of life
RR 30-60/min

Red flags

Retractions
Nasal flaring
Grunting
Tachypnea >60
Absent breath sounds (pneumothorax)

Cardiac assessment

Normal

HR 110-160 bpm
Murmurs common in first 24 hours
Acrocyanosis normal

Abnormal

Central cyanosis
Persistent murmur
Weak pulses or femoral < brachial (suspect coarctation of the aorta)
HR <100 or >180 sustained

A two-panel infographic shows how to assess newborn peripheral pulses. On the left, a clinician's fingers palpate the brachial pulse on the infant's upper arm, then the femoral pulse in the groin crease of the diapered newborn, who lies with arms and legs extended. On the right, two close-up circles compare a normal strong femoral pulse (labeled 'Normal') with sound wave lines to a weak, diminished femoral pulse (labeled 'Weak') with fewer wave lines, accompanied by a note that diminished femoral pulses suggest coarctation of the aorta. — Assessing peripheral pulses in the newborn

Abdominal & GI assessment

Normal

Soft, round abdomen
Bowel sounds present
Meconium within 24 hours
Umbilical cord: 2 arteries + 1 vein

Abnormal

Distended, rigid abdomen
Absent bowel sounds
Failure to pass meconium (Hirschsprung, CF)
Single umbilical artery (renal or cardiac anomalies)

Genitourinary assessment

Normal

First void within 24 hours
Scrotal swelling (hydrocele)
Pseudomenstruation in newborn girls
Labial swelling, vernix in folds

Abnormal

Ambiguous genitalia
Hypospadias/epispadias
No urine after 24 hours
Enlarged clitoris + fused labia (CAH concern)

Musculoskeletal assessment

Normal

Flexed posture
Equal limb movement
Symmetric folds
Spine straight

Hip dysplasia screening

Ortolani & Barlow tests
Uneven gluteal folds → suspicion

Two panels compare hip-dislocation screening maneuvers on a newborn model. Left panel (Barlow): examiner's fingers rest on the lateral hip and thumbs on the medial thigh while adducting the legs with posterior pressure, testing whether the hip can be dislocated. Right panel (Ortolani): examiner's fingers rest over the greater trochanter while abducting the legs with an anterior lift, producing a palpable clunk at the joint line as a dislocated hip reduces. — Ortolani and Barlow hip assessment maneuvers

Abnormal

Limb asymmetry
Clubfoot
Polydactyly
Neural tube defects (tuft of hair, sacral dimple with base not visualized)

Gestational age assessment (Ballard exam)

When the newborn’s gestational age is uncertain from maternal dates, the nurse can estimate it using the New Ballard score, a standardized scoring tool based on physical and neuromuscular maturity.

Neuromuscular maturity signs: posture, square window (wrist flexion), arm recoil, popliteal angle, scarf sign, and heel-to-ear.
Physical maturity signs: skin texture, lanugo amount, plantar surface creases, breast tissue, eye/ear development, and genital maturity.
Each sign is scored, the scores are totaled, and the total maps to an estimated gestational age in weeks.
The resulting score classifies the newborn as preterm, term, or post-term, which sets expectations for findings like vernix, lanugo, and reflex strength seen elsewhere in the assessment.

Neurological assessment

Normal newborn reflexes

Reflex	Expected response	Disappears
Moro (startle)	Arms extend then flex	4-6 months
Rooting	Turns to cheek touch	4 months
Sucking	Rhythmic sucking	6 months
Palmar grasp	Grasps object	6 months
Plantar grasp	Toes curl downward	9-12 months
Babinski	Toes fan out	1 year
Stepping	Stepping motion when upright	4-8 weeks
Tonic neck	“Fencing” posture	3-4 months

Abnormal findings

Absent reflexes
Persistent reflexes beyond expected age
Seizure-like activity
High-pitched cry

Definitions

Lanugo: Fine newborn hair, more common in prematurity.
Moro reflex: Startle response; absence suggests neurologic injury.
Cephalohematoma: Blood under periosteum; jaundice risk.
Ortolani/Barlow: Tests for congenital hip dysplasia.

Clinical instance: Cephalohematoma and jaundice risk

A newborn appears pale and irritable. The nurse notes a large cephalohematoma and rising bilirubin. Recognizing the risk for hyperbilirubinemia, the nurse notifies the provider, obtains a serum bilirubin level, and initiates phototherapy as ordered, preventing progression to kernicterus.

Client education

The caregiver or family is the client for newborn teaching, since the newborn cannot participate in their own care. Teach the client to expect the following:

Milia, Mongolian spots, and peeling skin are normal in the first days.
6-8 wet diapers/day by the end of the first week are expected.
Report poor feeding, fever, or persistent vomiting to the provider.
Redness or foul smell from the umbilical cord is not normal and should be reported.
Sneezing and hiccups are common and are not signs of illness.

Common pitfalls on the NCLEX:

Mistaking central cyanosis for normal acrocyanosis.
Assuming delayed meconium or urine is “normal.”
Ignoring absent red reflex; this is serious.
Overlooking asymmetric limb movement (nerve injury or fracture).
A primitive reflex is abnormal only when it persists past its expected disappearance age; the same reflex present in a newborn is a normal finding, so judge persistence against the newborn’s expected age band.

Next | 2.3.3 Feeding, elimination, and daily care

Comprehensive newborn assessment

Introduction

On the NCLEX, newborn assessment questions test your ability to discriminate normal transitional findings from red-flag abnormalities.

Learning objectives

By the end of this section, you should be able to:

Perform a complete newborn head-to-toe assessment, including skin, head, respiratory, cardiac, abdominal, musculoskeletal, and neurological domains.
Distinguish normal transitional findings from abnormal or pathological findings.
Recognize early signs of sepsis, respiratory distress, birth trauma, and congenital abnormalities.
Interpret common newborn reflexes and understand their developmental significance.
Identify normal elimination patterns and indicators of dehydration or GI/GU obstruction.
Assess gestational age using standardized tools (Ballard exam).

Newborn measurements (baseline)

These measurements give the first clues about growth, gestational age, and potential complications.

Weight: 2500-4000 g (5.5-8.8 lbs)
- Weight loss up to 10% in the first week is normal
Length: 18-22 in (45-55 cm)
Head circumference: 32-36.8 cm
Chest circumference: 30-33 cm
Temperature: 36.5-37.5°C
HR: 110-160 bpm
RR: 30-60/min

General appearance

Normal transitional findings include:

Flexed posture
Strong cry
Pink coloring with possible acrocyanosis
Lanugo (fine hair) on shoulders/back
Vernix caseosa (white creamy coating)

Abnormal:

Limp or hypotonic posture
Weak or high-pitched cry (neurologic concern)
Pallor or central cyanosis
Flaccidity
Poor weight or abnormal proportions