General Observation
Vital Signs
Skin Assessment
Neurological Assessment
Respiratory Assessment
100

The passage of meconium is expected within this timeframe in a healthy term neonate

What is 24-48 hours?

100

The average heart rate range for a term neonate.

What is 120–160 beats per minute?

100

This benign, transient pustular eruption of term neonates consists of small pustules on an erythematous base, peaks at 24–72 hours, and contains eosinophils on Wright stain.

What is eythema toxicum

100

This soft, fluctuant scalp swelling that crosses suture lines and is present at birth

What is caput succedaneum?

100

This is a sign of increased work of breathing, seen as chest indrawing.

What is retractions?

200

On fundoscopic examination of a neonate, the red reflex is asymmetric—brighter on the left, white on the right.

What is leukocoria?

200

The normal respiratory rate for a term infant.

What is 30–60 breaths per minute?

200

The bluish coloring of hands and feet, common and benign in newborns.

What is acrocyanosis?

200

The reflex when arms and legs extend and then flex after a sudden loud noise.

What is the Moro reflex?

200

High-pitched breath sounds heard with a stethoscope.

What is wheezing?

300

This physical observation may indicate dehydration in a newborn.

What is sunken fontanelle?

300

The term for periods of breathing cessation lasting longer than 20 seconds.

What is apnea?

300

On abdominal assessment of a neonate, the nurse observes a defect at the umbilical ring with herniation of abdominal contents covered by a membrane of peritoneum and amnion.

What is omphalocele

300

The absence of this reflex in a term baby may indicate neurological injury.

What is the suck reflex?

300

A rapid, irregular breathing pattern can indicate this immature condition.

What is periodic breathing?

400

A neonate born at 38 weeks has bilateral failure to pass a suction catheter through the nasal passages. The infant maintains SpO2 in room air only while crying. This condition is called this

What is choanal atresia?

400

This sign may indicate infection, hypothermia, or environmental issues in the NICU.

What is abnormal temperature?

400

This skin finding indicates infection risk related to IV or lines.

What is erythema or induration at insertion site?

400

This reflex is checked by stroking the sole and observing toe movement.

What is the Babinski reflex?

400

A neonate is noted to have micrognathia, a posteriorly displaced tongue causing intermittent airway obstruction, and a U-shaped cleft palate. This clinical triad constitutes this eponymous sequence

What is choanal atresia?

500

This sign, involving bulging fontanelle and irritability, suggests increased intracranial pressure.

What is tense fontanelle?

500

In neonates, hypotension can be defined by this blood pressure threshold.

What is a mean arterial pressure less than gestational age?

500

Fine downy hair seen on premature infants.

What is lanugo?

500

Unequal pupil size in a neonate could indicate this potentially dangerous condition.

What is intracranial hemorrhage or other neurological abnormality?

500

The technique for quickly checking the adequacy of oxygenation in NICU.

What is pulse oximetry?