IMMEDIATE CARE OF THE NEWBORN

DESCRIPTION

Immediate care of the newborn are care of the baby that needs to be given at birth in the
labor and delivery room. The first 24 hours of life is a very significant and a highly vulnerable
time due to critical transition from the intrauterine to extrauterine life.
The essential newborn care protocol is a series of time bound and chronologically ordered
care that a baby receives at birth , and it has standardized effective procedural steps: dry and
stimulate, evaluate breathing, cord care, keep the newborn warm, initiate breastfeeding within
the first one hour, administer Vitamin K intramuscularly, place the newborn’s identification
bands, weigh the newborn when it is stable and warm, and record all observations and
treatment provided.

PURPOSE: 1. To obtain baseline evaluation of anthropometric measurements.

2. To administer prophylactic medications & vaccines.
3. To determine the critical transition from the intrauterine to extrauterine life.
4. To provide basis for future evaluation and determine the infant’s progress.

PLANNING

EQUIPMENT REQUIRED
 Gloves
 Eye ointment
 1cc Syringe (3)
 Vitamin K ampule
 Hepatitis B vaccine
 BCG vaccine
 Cotton balls (dry and wet)
 Weighing scale
 Tape measure
 Alcohol
 Underpad /Paper
 Digital thermometer
 Baby dress
 Diaper

IMPLEMENTATION

Directions: Please rate the students’ level of competency on each expected skill using
the scale provided.
 0 – NOT DONE
1 – DONE WITH ASSISTANCE
2 – DONE INDEPENDENTLY

After the baby completes her first breastfeed and detaches to the breast CARRY OUT THE
CREDE’S PROPHYLAXIS, VITAMIN, VACCINES and ANTHROPOMETRIC MEASUREMENTS.

SAFE AND 1. Gather all equipment/ Organizations facilitates accurate skill

QUALITY materials needed performance and to save time and
NURSING CARE energy.

2. Perform hand hygiene Handwashing prevents the spread of

possible infection

3. Wear sterile gloves Gloves protects from exposure to

blood or other body fluids.

SAFE AND 4. Perform the To ensure proper baseline evaluation

QUALITY anthropometric
NURSING CARE measurement using tape
measure to measure the
length, the head
circumference, chest
circumference and
abdominal circumference.

A. Head Circumference:

 Securely wrap the

tape measure
around the widest
possible
circumference of
the head

- Broadest part of the

forehead above
eyebrow

- above the ears

- Most prominent part

of the back of the head
 Normal HC:33-35 cm

B. Chest Circumference:

 Securely wrap the

tape measure
around the scapula
and over nipple
line.
SAFE AND
QUALITY Normal CC: 31-33 cm
NURSING CARE
C. Abdominal
Circumference:

 Pass the tape measure

around the abdomen at
the level of the
umbilicus.

Normal AC: 31-33 cm

D. Length

 Hold newborn’s head at

midline point and
extend legs fully.

 Stretch the tape

measure from crown of
newborn’s head to heel
of newborn’s foot
alongside the
newborn’s body.

 Note and record

newborn’s height in
centimeters

Normal:46-55 cm
SAFE AND 5. Weigh the baby. Weigh To provide basis for future evaluation
QUALITY the baby an hour after and determine the infant’s progress
NURSING CARE the first breastfeed
 Place light drape or
paper on weighing
scale.
 Calibrate scale to “ 0”
position.
 Wearing no clothes the
infant is placed on the
center of the weighing
scale tray and never be
left unattended on the
scale.
 Keep one hands over or
SAFE AND
near the newborn on
QUALITY
the weighing scale at all
NURSING CARE
times
 Read the weight of the
newborn.
 Carefully removes
newborn from weighing
scale.
 Record the weight.

Normal:2.5- 3.5 kg

6. Take the rectal To rule out imperforate anus.

temperature of the infant:
 Disinfect / wipe the
thermometer with wet
cotton balls
 Lay the infant or place
SAFE AND the infant in his back
QUALITY with his knees pulled
NURSING CARE up.
 Insert the bulb end of
the thermometer into
the anal canal no more
than 1 inch.
 Keep the thermometer
in place until it beeps,
 or for at least one
minute.
 Remove the
thermometer and read
the result.
 Disinfect the
thermometer with
rubbing alcohol or an
alcohol based wipe.

MANAGEMENT 7. Open the Erythromycin To prevent contamination and

OF ointment. Make sure not to maintain sterilization of the ointment.
ENVIRONMENT touch the lid of the
AND RESOURCES tube/container.

SAFE AND 8.Give eye care by putting To protect the baby from serious eye
QUALITY Erythromycin eye ointment infection which can result in blindness
NURSING CARE into the newborn’s eye. or even death.
 Hold/ retract one eye
MANAGEMENT open and apply a rice
OF grain of ointment along
ENVIRONMENT the inside of the lower
AND RESOURCES eyelid from inner
canthus to outer
canthus. Make sure not
to let the tip of the tube
touch the baby’s eyelid.
 Repeat the same
procedure on the other
eye.

9. Give the baby Vitamin K, To prevent hemorrhagic bleeding.

SAFE AND 1 mg (0.1 cc) via
QUALITY intramuscular injection (IM)
NURSING CARE on the upper outer
quadrant of the left vastus
lateralis
 Wipe the vastus
lateralis with wet
cotton balls in a
circular motion
 Inject
intramuscularly the
 0.1 cc of Vitamin K
on the vastus
lateralis and apply
pressure.

10. Administer Hepatitis B To prevent hepatitis B infection

SAFE AND vaccine 0.5cc on the upper
QUALITY outer quadrant of the right
NURSING CARE vastus lateralis via
intramuscular injection (IM)
 Wipe the other
vastus lateralis with
wet cotton balls in a
circular motion
 Inject
MANAGEMENT intramuscularly the
OF 0.5 cc of Hepatitis B
ENVIRONMENT on the vastus
AND RESOURCES lateralis and apply
pressure.

SAFE AND 11. Administer BCG 0.05 cc To prevent pulmonary tuberculosis

QUALITY intradermally on the deltoid infection
NURSING CARE area / buttock

 Wipe the deltoid

area / buttock with
wet cotton balls in a
circular motion.
 Inject intradermally
the 0.05 cc of BCG
on the deltoid area /
buttock. Do not
massage.

Note: Upper outer

quadrant of the
buttock

12. Dress the baby with To kept the baby warm and to prevent
clean clothes and hypothermia.
diaper
 13. Discard used supplies To prevent the spread of infection.
and remove gloves.

14. Perform medical Handwashing prevents the spread of

handwashing possible infection.

RECORDS 15. Document findings of Provides evidence of client care.

MANAGEMENT/ the procedure.
LEGAL
RESPONSIBILITY

EVALUATION
 Evaluate for any signs of Respiratory Distress syndrome.
 Evaluate the baby’s adaptation to extra uterine life.
 Evaluate for any abnormalities or congenital defects.
 Evaluate for any untoward or unusual signs and symptoms and findings.
 Evaluate for good sucking reflex.

NURSING CONSIDERATION
 Bathing the baby should be delayed for 6 hours.
 Initiate breast feeding within the first hour after birth.
 Keep the baby dry and warmth to minimize heat loss.
 Keep the mother and baby together for as long as possible to promote bonding.
 Delay tasks such as weighing, bathing, eye care, injections, etc. until after the first feed

REFERENCES:
[1]Berman, A., Snyder, S., Kozier, B. & Erb, G. (2016). Kozier & Erb’s Fundamentals of Nursing:
Concepts, Process & Practice, 10th edition. USA: Prentice Hall. Page 330

[2]Murray, S. S., McKinney, E. S., Holub, K. S., & Jones, R. (2019). Foundations of Maternal-Newborn and
Women's Health Nursing (7th ed.). St. Louis: Elsevier. Page 569-573

[3]Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2017). Fundamentals of Nursing (9th ed.). St.
Louis, MO: Mosby Elsevier. Page 402-203
[4]Serrano, M. [2018, January]. Knowing Unang Yakap Campaign. Retrieved June 26, 2020
from https://www.rnspeak.com/knowing-unang-yakap-campaign/

[5]Unang yakap DOH EINC - [PDF Document]. (2018, June 03). Retrieved June 26, 2020 from
https://vdocuments.site/unang-yakap-doh-einc.html

[6]World Health Organization (2018). WHO recommendations on intrapartum care for a positive
childbirth experience. Pages 162-164

Computation of Grades:
STEP 1 : Get the sum of all the points for the entire procedure
STEP 2 : Use the formula below to get the final grade for the particular competency
checklist.

FORMULA: RAW SCORE / PERFECT SCORE X 75 + 25 = FINAL GRADE

Evaluated by: Conforme:

___________________________________ ____________________________________
Signature over printed name Signature over printed name
(Clinical Instructor) (Student)

Date: _____________________________ Date: _____________________________