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Newborn Initial Assessment

  1. Perform hand hygiene and apply clean gloves.
  2. Receive the infant from the physician or midwife and transfer to preheated warmer bed and quickly assess for obvious abdominal or spinal defects. Obtain time of birth and start Apgar timer if available.
  3. Place the infant's head in the neutral sniffing position to open airway; may use blanket rolls to maintain infant position if necessary.
  4. Suction to remove excess secretions from the infant's mouth first and then the nose using the bulb syringe. Progress to more invasive suctioning techniques as required. Assess palate condition and nasal patency.
  5. Dry the infant thoroughly and stimulate breathing by rubbing the infant's back and feet. Assess overall skin integrity.
  6. Remove wet linen from bed and then place the infant on the pre-warmed dry blankets beneath. Apply hat to the infant's head, briefly noting shape, symmetry, and scalp integrity. Apply the skin temperature probe to the right upper quadrant of abdomen with reflective disk.
  7. Obtain 1-minute Apgar score.
  8. Repeat suctioning and administer O2 as indicated by the Apgar score and infant presentation. Quickly do a preliminary gestational age survey if the infant's gestational age is unknown.
  9. If the infant is stable, evaluate temperature rectally using an approved thermometer, or per institutional policy. Simultaneously evaluate rectal patency. Do not force thermometer. If temperature is within normal range (36.5-37.2° C), the nurse may obtain the infant's weight at this time using a clean baby scale.
  10. Obtain 5-minute Apgar score to evaluate effectiveness of resuscitation.
  11. After verifying the exact ID band information with the mother, apply one band to the infant's wrist and the other to the opposing ankle, or per institutional policy. Footprint infant per institutional policy.
  12. Verify orders and two patient identifiers; then administer prophylactic eye ointment and vitamin K as ordered.
  13. Wrap the infant securely in clean, dry, warm linen.
  14. Place the infant in the mother's arms for bonding time if possible.
  15. Remove gloves and discard in proper trash receptacle. Perform hand hygiene.
  16. Document the procedure in the patient's record.