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JMJ Marist Brothers NOTRE DAME OF MARBEL UNIVERSITY College of Health Sciences Nursing Department

Name: ___________________________________________ Group: _____________________ Clinical Instructor: __________________________________ Rating: _____________________


DEFINITION: Early management of the newborn in the delivery room or in the nursery or few minutes or soon after birth.

PURPOSES: 1. To establish and maintain patent airway for the newborn. 2. To promote measures to prevent hypothermia. 3. To prevent complications. 4. To prevent infection to set in. 5. To record observations of the infants condition.

EQUIPMENT: 1. 2. 3. 4. 5. 6. 7. 8. Sterile linen Pair of sterile gloves Rubber bulb suction Suction machine Suction catheter (French 5 and 8) Rectal thermometer Alcohol swabs Cord clamp 9. Sterile babys layette

10. 10% Providone Iodine swabs 11. 1 cc syringe 12. Terramycin eye ointment 13. Stamping pad 14. Agency form for babys footprints 15. Name tag 16. Basin with lukewarm water

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

17. Antiseptic or mild soap 18. Droplight 19. Water soluble lubricant 20. Weighing scale

21. Tape measure 22. Sterile gauze 23. Baby oil 24. Babys comb

ASSESSMENT 1. Within 60 seconds after the infants body is completely born, evaluation should be done by Apgar Scoring. 2. In the delivery room, perform a general physical assessment of the infant. PLANNING 1. Wear mask, cap and gown. 2. Wash your hands. 3. Assemble all necessary equipment. IMPLEMENTATION 1. Don gloves. 2. Care of skin. A. Using sterile gauze with baby oil, gently wipe the infants body starting from the face down to the feet. Do not remove all vernix caseosa.

RATIONALE Each sign in the Apgar Scoring system is an index of the infants depression or lack of it at birth. To find out any gross abnormalities or evidence of shock or birth trauma. To protect the newborn from microorganisms which may possibly come from the personnel. Deters the spread of pathogenic microorganisms. To facilitate easy access, therefore assuring an organized work. To prevent nosocomial infection and maintain the sterility of the procedure. To cleanse secretions obtained from passage through the birth canal which may become a source of infection. Gentle approach will prevent tissue damage. Vernix caseosa may give protection to infants skin by acting as a lubricant. Besides, vernix caseosa naturally disappears as it rubs on crib linens or on infants clothing. Gauze alone cannot remove blood and dirt that are interspersed with hair strands. Removes excess blood or vernix caseosa from the infants skin and to enhance the newborns smell. To prevent spread of microorganisms and promote cleanliness and orderliness. To maintain sterility. Following the clean to dirty principle helps prevent recontamination of the cleansed areas. Disinfect the chord to prevent infection or complications because the cord is considered an open portal of bacterial entry.

B. Hair is gently wiped or combed. C. If a protocol of the hospital, bath the baby with lukewarm water and an antiseptic or mild soap. D. Remove gloves and dispose in appropriate receptacle. 3. Care of the cord. A. Don sterile gloves. B. Holding the clamp, roll the cord up to 4 inches above the newborns abdomen. Disinfect the cord starting from the base in an upward direction with the use of a cotton ball soaked in antiseptic solution.

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

Use one cotton ball per stroke and ensure that all areas of the cord is disinfected. C. Clip the cord clamp or tie the cord securely one inch from the base and cut it off just above the clamp or tie. D. Inspect the cord for any undesirable signs. E. Apply antiseptic solution 70% Isopropyl alcohol or Betadine 10%. F. Dress the cord aseptically by wrapping it with sterile gauze. G. Wet the cord stump adequately with 70% isopropyl alcohol before covering it with sterile gauze. H. Securely keep it in place by wrapping it with an abdominal binder if it is a hospital protocol. 4. Do proper evaluation of the infant using anthropometric measurements (head, chest, abdominal circumference, length and weight) and record. 5. Stabilization of body temperature.

Inspection will help find out cord abnormalities such as bleeding, foul smelling secretions, redness and swelling, w/c are signs of possible infection. To thoroughly disinfect the entire area and minimize the possibilities of infection. That is to maintain the aseptic technique and prevent risking the infant for infection and complications. The gauze will serve as protection for the cord from bacterial entry. To ensure that the gauze is totally soaked with antiseptic so that there will be no possibilities of infection or complication. To prevent the gauze from being dislodged or removed. The binder will keep the dressing in place and will prevent complications, more so bleeding. To provide necessary information w/c are indices of abnormalities and to provide baseline data for the future progress of the newborn. To check the newborns temperature since the thermostat his temperature regulating system is still immature. To check anal imperforation to find the need for any management. To protect the infant from chilling since the newborn is still sensitive to the sudden change of temperature outside the uterus. To prevent Opthalmia Neonatorum. Vitamin K is a blood coagulant therefore it protects the newborn from bleeding tendencies. (Vit.K is supposed to be synthesized by the normal bacterial flora of the gastro intestinal tract, but since the newborns GIT is sterile at birth, there is no bacterial flora to synthesize Vit.K, so it has to be provided by an external source.) To prevent mistakes in the proper identification of the baby.

A. Insert a rectal thermometer gently and record the infants temperature. Observe for unusual findings. B. Clothe the infant and wrap him properly. 6. Apply Credes prophylaxis on both eyes. 7. Prepare Vitamin K 0.5mg (.05ml) for preterm infants and 1 mg (.1ml) for term infants and inject it intramuscularly into the newborns vastus lateralis muscle.

8. Place the infants identification band around the wrist or ankle with the name and sex of the infant, the mothers name, attending physician and the date and time delivered. Get the babys footprints and record it in the chart. 9. If the baby developed serious complications,

The nurse should respect the rights of the

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

the nurse is responsible to coordinate with the representatives of the affiliated religious groups. 10. If the infant remains in the nursery, place him/her comfortably in the crib or bassinet. 11. If the hospital practices rooming in, bring the infant to the mothers room and give proper instructions on newborn care.

clients. To promote comfort, sleep, and rest on the part of the infant as well as warmth to prevent hypothermia. To promote attachment and maternal-infant bonding and cuddling, and also to allow other family members to see the newborn. Health teaching is one of the most basic responsibility of the nurse to promote understanding and provide additional knowledge. Prevents the spread of pathogenic microorganisms. - To prevent nosocomial infections. - Disinfect the equipment before storing it to have it ready for use the next time. - To prevent it from getting contaminated if mixed with other items. - To have it ready for future use and prevent contamination. To ensure that future complications are prevented and that the infants condition is stable. To ensure proper airway clearance and prevent respiratory complications. To prevent infection or unnecessary skin rashes or allergies. To prevent infection and complications. The cord is considered an open skin which is at risk for infection and bacterial growth if not properly taken cared of. To ensure that the possibility of hypothermia is prevented and to establish warmth for the infant that is necessary for a newborn.

12. Do after care. A. Discard all used supplies. B. Clean thermometer properly. C. Place babys social linens in an appropriate hamper. D. Wash and dry instruments. EVALUATION 1. Infection is prevented. 2. Respiratory function is well established. 3. Skin care has been done properly. 4. Cord is taken cared of and assessed for unusual findings. 5. Temperature has been stabilized.


Apgar Scoring the numerical expression of a newborn infants well-being and ability to

Vernix Caseosa a white, cream cheese-like substance that serves as a skin lubricant;
usually noticeable on a newborns skin at birth in a term nenonate.
Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

Opthalmia Neonatorum eye infection at birth or during the first month, most commonly
caused by Neisseria gonorrhoeae or Chlamydia trachomatis NOTE: can result to corneal ulceration and destruction (severe vision impairment) if left untreated.

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care