How To Perform a Neonatal Assessment in the NICU

Hi friends, in this video I am going to show you how to perform a neonatal assessment on a NICU patient. This is my routine assessment that I do every few hours when it’s time for my patient’s “cares”—their hands-on time. It’s important to work quickly and efficiently, especially the younger the gestational age, so here’s my flow as I work least to most invasive and from top to bottom. I’m hitting the highlights of a routine assessment in this video, but below you’ll find a detailed, normal NICU assessment.      

00:00 Begin Here  
01:05 Before You Start
03:44 Hands-On Assessment  

🧠 Neurological  
Equal and reactive pupils No head abnormalities (no molding, caput, cephalhematoma, forcep marks)  
Anterior fontanel open and soft
Posterior fontanel open
Sutures approximate  
Moves all extremities equally  
Moro, suck, rooting, and palmar grasp present

🫀 Cardiovascular
Regular rhythm/clear audible without murmur
Pulses present and equal in all extremities
Capillary refill upper and lower extremities less than 3 sec
Mucus membranes pink and moist
No edema

🫁 Respiratory
Chest expansion symmetrical
Non-labored respiratory effort
No retractions
Clear and equal breath sounds    

💩 Gastrointestinal  
Soft, rounded, pink, non-distended abdomen
Bowel sounds audible 4 quadrants

💦 Genitourinary
Voiding per diaper
Yellow urine

👶🏻 Skin
Warm, dry, intact
Normal skin turgor
Occiput, sacrum, and heels intact
No diaper dermatitis present  

This content was peer-reviewed for accuracy by Christine McQuay, MHA, MSHI, BSN, RN, RNC-NIC.

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I’m Anna and I am a critical care registered nurse. I have worked in the NICU, PICU, pediatric floor, and on my hospital’s critical care children’s transport service. I am also a nursing instructor and love teaching students and new nurses!

Disclaimer: This video is intended for educational purposes only and is not indented as medical advice. While I strive for 100% accuracy, errors may occur and practices may change over time.

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