Ateneo de Zamboanga University

COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST

NAME: _____________________________________ DATE PERFORMED: ______________

YEAR & SECTION: ______________

Purposes:

1. To ensure an airway and maintain respiration.

2. To prevent cold stress (hypothermia)
3. To provide a time for complete observation.
4. To stimulate circulation as adequate to maintain health.

IMMEDIATE CARE OF THE NEWBORN COMPETENCY

PREPARATORY PHASE 1 2 3 4 5
I. Management of Resources, Environment and
Equipment
1. Prepares instrument and equipment needed:
Suction bulb, cord clamp, gauze, cotton balls,
disinfectant, blanket, droplight, vitamin K,
antimicrobial ophthalmic ointment.
2. Ensures use of sterile equipment during
immediate care of the newborn.
3. Maintain adequacy of supplies as newborn care
is rendered
4. Maintains orderliness of the working area.
5. Observes precautionary measures related to use
of electrical equipment.
6. Ensures a warm and quite environment.

7. Uses supplies diligently.

II. Legal Responsibility

8. Identifies newborn by comparing ID band with
data in the chart.
9. Documents all pertinent data correctly and
completely.
10. Reports accurately any deviation/abnormal
findings and nursing interventions rendered.
11. Ensures that birth certificate and other civil
registration forms are accomplished/ filled out
according to institutional policy.
12. Performs foot printing according to hospital
policy.
III. Ethico-Moral Responsibility
13. Respects the religious, cultural and ethnic
practices of the family of the newborn.
14. Maintains privacy and confidentiality of findings
of assessments.
IV. Personal and Professional Development
15. Updates oneself with the latest trends and
developments in newborn care.
16. Projects a professional image of the pediatric
nurse.
17. Accepts criticisms and recommendations,
performs functions according to standards.
PROCEDURE

I. Safe and Quality Nursing Care

18. Establishes and maintains patent airway.

19. Puts the newborn in Trendelenburg position

20. Suctions mouth and nose of the newborn gently

21. Dries newborn and wraps warmly
 Place under droplight as needed
22. Performs and interprets APGAR scoring
correctly.
 Immediately after delivery
 After 5 minutes
23. Ensure proper identification of newborn (name
tag; name of mother, date and time of delivery,
gender and name of attending physician).
24. Performs physical assessment.
25. Takes anthropometric measurements including
weight, height, head, chest, abdominal
circumference.
26. Takes vital signs (temperature per rectum to
check patency)
27. Gives oil/water & soap bath according to
institutional policy.
28. Latches newborn to the mother’s breast
immediately after birth.
29. Applies Crede’s prophylaxis on the eyes.
30. Performs cord dressing aseptically.
 Disinfects area properly according to hospital
policy
 Clamps and cuts cord 1 inch from the
abdomen
 Checks for the presence of 2 arteries and 1
vein
 Dresses cord aseptically according hospital
policy
31. Administers vitamin K (1 mg/Ml) into the lateral
anterior thigh of vastus lateralis.
32. Keeps baby wrapped warmly under droplight or
bedside mother according to institutional policy
until discharge.
33. Records pertinent observations and nursing care
done.
34. Reports any signs of deviation/abnormality to the
pediatrician.
II. Legal Responsibility
35. Identifies newborn by comparing ID band with
data in the chart.
36. Documents all pertinent data correctly and
completely.
37. Reports accurately any deviation/abnormal
findings and nursing interventions rendered.
38. Ensures that birth certificate & other civil
registration forms are accomplished/filled out
 according to institutional policy.
39. Performs foot printing according to hospital
policy.
III. Health Education
40. Provides instructions to the mother on daily cord
care and prevention of cord infection.
41. Provides discharge instructions to the mother on
when to expect cord to fall off or to report signs
of cord infection.
42. Provides information regarding newborn
screening, immunization, feeding, etc.
43. Responds to questions of mother and relatives
regarding expectations.

TOTAL

___________________________
Clinical Instructor
(sign over printed name)

1 2 3 4 5
Preparation

Procedure
2.

3.

4.
5.

6.

7.

8.

9.

10.

11.

T
OTAL