Meet a Neonatal Nurse
| NurseJournal Staff
In hospital maternity wards, many babies arrive healthy and can leave the hospital a few days after birth. Other infants face challenges adjusting to life outside the womb including anemia, breathing problems, and jaundice.
Neonatal nurses play an important role in caring for these newborns, keeping them alive and nursing them to health. The National Association of Neonatal Nurses describes the profession as "a subspecialty of nursing that works with newborn infants with a variety of problems, ranging from prematurity, birth defects, infection, cardiac malformations, and surgical problems."
Like any other nurse, neonatal nurses need the proper degree and nursing licence. However, they also may pursue a certification in the neonatal nursing specialty. This page provides useful information about how to become a neonatal nurse and what you can expect in this career. You can find more about career and salary outlooks for NICU nurses with this resource.
Q&A With a Neonatal Nurse
Megan is a level IV neonatal intensive care nurse who specializes in caring for infants with congenital heart defects. She graduated with her BSN in 2014 and holds certification in neonatal intensive care and lactation counseling. In early 2020, Megan used her NICU background and became a "nursepreneur" by launching Bright & Baby, which provides virtual resources and prenatal classes for expectant and new parents. Megan lives in Jersey City, New Jersey, with her partner, Patrick, and their son, Ryan.
Preferred Pronouns: She/her
I realized I was drawn toward neonatal care during my maternity clinical in nursing school. I was able to shadow a NICU nurse taking care of a baby in a level II NICU in a small community hospital. During nursing school, I worked as a nursing assistant on an adult oncology floor. When it came time to apply for nursing jobs, those already employed by the hospital got "first dibs." I decided to apply to both ER, with my background in EMS and NICU, since I loved my experience during clinical. NICU happened to have a spot open, and I'm so glad it worked out that way.
The relationship between neonatal nurses and labor and delivery nurses can vary from hospital to hospital. NICU nurses might be present and working alongside L&D nurses at the time of high-risk deliveries, respond to infant emergencies in L&D, or assist the L&D nurse in monitoring the baby during transition. In some institutions, those roles might be filled by NPs, medical residents or fellows, or hospitalists instead. In small rural hospitals, an L&D nurse might be expected to care for the sick neonate until the baby can be transferred to a hospital with a NICU. It all depends.
When starting in the NICU, a big challenge is that "you don't know what you don't know." Nursing school only brushes the surface of neonatal nursing, if at all. NICU babies are unlike any other population since their care is so specific that you can't learn it elsewhere. I'd highly recommend purchasing and skimming through a neonatal certification preparation book once hired but before starting orientation. That way, you're at least familiar with neonatal terminology.
I currently work in a level IV cardiac NICU. A "typical day" with a critical one-to-one patient might look like:
7:00-8:00: Receive report from night shift, re-scan and check all continuous infusions, check orders, safety checks (ambu bag, suction, alarm parameters, emergency dosage calculations), check breastmilk/formula fridge, prepare for rounds, wipe every surface with PDI wipes, sip coffee.
8:00-9:00: Initial "care" time. Head-to-toe assessment of infant, checking neurological, cardiovascular, respiratory, GI, GU, skin status. Pain assessment. Assessment of IV and PICC sites. What does the dressing and site look like? Is the dressing due? Is the line unclamped from base to medication? Assessment of surgical incision site. ETT and naso/oropharyngeal suctioning. Gavage or compressed feeding, warm and scan breastmilk. Medication administration via IV, gastric tube, duodenal tube, or nebulization. Diaper change. Reposition infant and developmental care (sound, lights, touch, smell).
9:00: Medical rounds with neonatology attending and fellow, pediatric cardiology attending and fellow, mid-level provider (NP, PA, hospitalist), nutrition, pharmacy, charge nurse, and family. Discuss the plan for the day and overall goals.
9:30: Make any changes discussed on rounds and coordinate with techs any imaging/tests (X-ray, EKGs, ultrasound) ordered.
10:00: Chart! Continuous monitoring of the infant (vitals, pain/sedation, need for airway suctioning). Emotional support of the family.
11:00, 14:00, 17:00 (or with cues): Repeat "care" times, assessment, diaper change, reposition, feeding.
Throughout the day: continuous monitoring of infant's status, charting, medication administration, updating the mid-level provider and family.
Babies are less fragile and more resilient than we think.
Join professional organizations at the student discount rate to start learning more about the NICU. I'd recommend joining the National Association of Neonatal Nurses (NANN) or the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). They both have journals (available electronically) that you can read and start learning more about the field.
Some hospitals hire new graduate nurses directly into the NICU. Don't be afraid to apply to the NICU, even if you don't have experience.
Finally, if you're able to balance working and nursing school, I'd highly recommend applying for non-nursing jobs at the hospital you want to work at eventually as a nurse. There are plenty of options, like nursing assistant, patient transport, and unit clerk, that can offer flexible schedules (per diem, 3:00-11:00 p.m., etc.). You'll already be "in the system" when it's time to apply for your nursing job. And you'll already be familiar with the hospital's mission and values, policies, overall culture, etc.
What Does a Neonatal Nurse Do?
When children are born in hospitals, they go into one of four levels of neonatal care: well newborn (I), special care nursery (II), neonatal intensive care unit (NICU, III), and regional NICU (IV). Neonatal nurses care for infants in the last three levels who need the most specialized care. The intensive natal units require demanding and round-the-clock care from nurses. Although neonatal nurses sometimes work in delivery rooms and non-intensive maternity wards, their primary roles occur in the NICU.
NICU nurses assist with procedures, give patients their medication, and perform tests to evaluate how babies adapt to care. They work with specialized equipment like incubators, blood pressure monitors, endotracheal tubes, respirators, and ventilators. These professionals care for infants, provide guidance to mothers, and comfort families.
Newborns do not follow a schedule, which means NICU nurses always need to be on duty in the NICU, working nights and weekends. They often work 12-hour shifts, although they may also work 8- or 10-hour shifts.
How to Become a Neonatal Nurse
Individuals can follow a few different educational pathways in order to become a newborn nurse.
Neonatal nurses need proper licensure. They can earn registered nurse (RN) licensure with either an associate degree in nursing (ADN) or a bachelor of science of nursing (BSN). Full-time ADN programs typically last two years, while a BSN traditionally takes four years to complete.
After graduating, nursing candidates take the NCLEX-RN exam and apply for RN licensure. With experience, they may qualify for specialty certification in neonatal care. Although neonatal nurses do not need certification in neonatal units, employers may show preference to candidates with certification. Two popular types of certification include the RNC Certification for Neonatal Intensive Care Nursing and Critical Care Registered Nursing (Neonatal) certification.
Nurses can also choose to pursue an advanced degree to become a neonatal nurse practitioner. A master of science in nursing (MSN) typically takes two years to complete and prepares students to work as nurse practitioners. These professionals take on more responsibilities than RNs. They can meet with patients on their own and in many states prescribe medication without a physician's supervision. An MSN also allows students to specialize in certain areas, such as neonatal care.
Salary for a Neonatal Nurse
According to the Bureau of Labor Statistics (BLS), RNs earn a median annual salary of about $73,300. Over 3 million RNs worked in the U.S. in 2019, a number the BLS projects to increase by 7% from 2019-29.
Although the BLS does not provide specific figures for neonatal nurses, data compiled by PayScale estimates that these professionals earn an average salary of about $70,600. Salaries may range from $49,000-$106,000.
Salaries vary by location. Registered nurses in states like California, Hawaii, Washington, D.C., Massachusetts, and Oregon earn the highest salaries, with mean wages for RNs in these states ranging from $93,000-$113,000, according to the BLS.
Healthcare professionals working as neonatal nurse practitioners typically earn higher salaries. Along with other advanced practice nurses, nurse practitioners earn a median annual salary of about $115,800. The BLS also projects the number of advanced practice nurses to increase by 45% from 2019-29 to become one of the fastest growing professions in the United States.
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