The Neonatal Neurologic Exam: What NICU Nurses Should Be Watching For

The neurologic exam is one of the most powerful tools NICU nurses use — not because it gives us a diagnosis, but because it helps us recognize when something is changing. Unlike heart rate or oxygen saturation, neurologic status doesn’t live on a monitor. It lives in how the baby moves, responds, wakes, feeds, and tolerates care.

For many NICU nurses, especially those working in Level II settings, the neuro exam can feel abstract or intimidating. In reality, it’s something nurses are already doing every shift. The key is learning how to observe intentionally, establish a baseline, and notice trends over time.

When should NICU nurses perform a neurologic assessment?

A neurologic assessment isn’t a one-time event. It should be performed:

• On admission or transfer, to establish a baseline before medications, procedures, or fatigue alter the picture

• As part of your routine daily assessment, even if it’s a focused neuro exam

• Any time you notice a change, including changes in alertness, tone, movement, feeding ability, or event patterns

• After significant physiologic stressors, such as hypoxia, hypoglycemia, hypotension, infection, or painful procedures

Serial exams matter. A single assessment may look “okay,” but comparing today’s exam to yesterday’s — or even earlier in the same shift — often reveals important trends.

Understanding the context matters

Neonatal neurologic exams are highly dependent on context. Before interpreting findings, consider:

• Gestational and corrected age

• Behavioral state (quiet alert vs sleepy vs overstimulated)

• Recent feeds or procedures

• Medications such as opioids, sedatives, or anticonvulsants

A baby who is appropriately sleepy after a feed may look very different from a baby who is difficult to arouse despite stimulation. Knowing what is expected for that baby helps you recognize when something isn’t.

What are NICU nurses actually assessing?

A bedside neurologic exam does not require memorizing every reflex or cranial nerve. Instead, it focuses on a few key domains:

• Level of consciousness and responsiveness

• Posture and spontaneous movement

• Tone, both passive and active

• Symmetry of movement

• Primitive reflexes such as suck and grasp

• Autonomic stability, including changes in heart rate, breathing pattern, or temperature

Observation is often more informative than stimulation. Watching how a baby moves at rest, how they respond to handling, and how they recover from care provides valuable neurologic information.

Subtle changes matter

Not all neurologic changes are dramatic. In fact, many of the most important early clues are quiet:

• A baby who is harder to arouse than earlier

• Decreased spontaneous movement

• Changes in tone, such as new floppiness or rigidity

• Asymmetry, with one side moving less than the other

• Feeding skills that suddenly don’t match the respiratory picture

• Repetitive movements that don’t stop with gentle containment

These findings may precede seizures, infection, metabolic disturbances, or evolving neurologic injury. Nurses are often the first to notice them because we are the ones performing repeated assessments.

What can an abnormal exam mean?

An abnormal neurologic exam is a sign, not a diagnosis. Potential causes include:

• Metabolic or physiologic issues (hypoglycemia, electrolyte abnormalities, hypoxia)

• Medication effects or accumulation

• Infection or inflammation

• Intracranial injury, hemorrhage, or ischemia

• Encephalopathy in the early newborn period

This is why early escalation matters. Waiting for changes to become obvious can delay evaluation and treatment.

When should NICU nurses escalate concerns?

NICU nurses should escalate immediately for:

• Suspected seizure activity

• Sudden unresponsiveness

• New focal neurologic deficits

• Significant changes in tone or posture

Escalate promptly for:

• Progressive lethargy or irritability

• Feeding regression without another explanation

• Repeated subtle changes that don’t fit the baby’s baseline

You do not need to name the diagnosis. Clear documentation of what has changed, when it changed, and how it differs from baseline provides critical information for providers.

The nurse’s role in neurologic outcomes

Neurologic injury often evolves over time. Early recognition, timely escalation, and clear communication can directly impact evaluation, monitoring, and long-term outcomes.

NICU nurses are uniquely positioned to detect early change because we see patterns others may not. Trusting your assessment — even when you can’t fully explain it yet — is not overreacting. It is expert nursing practice.

Final thoughts

A strong neonatal neurologic assessment isn’t about perfection. It’s about consistency. Establish a baseline, observe carefully, compare exams over time, and speak up when something changes. When it comes to neurologic status, early recognition is everything.