CANOSSA COLLEGE

College of Nursing

A Self Learning Module on Related Learning Experience

Focus: Care of Mother, Child, Adolescent, Well Clients

MODULE 8: Immediate Newborn Care

Course Code: NCM 107

Level Offering: 1st Semester, AY 2021-2022
Clinical Area of Assignment: Labor Room and Delivery Room/Lying-In Clinic/Neonatal
Intensive Care Unit
Date: December 10-11,2021, 2:00 pm–9:00 pm (Thursday, Friday, Saturday)

Module Overview:

This module is created to enrich your skills in the maternal and child nursing.
Module 8 is designed to develop your skills in nursing care associated with newborn
and newborn family. This is also focuses on newborn assessment and care. The student
needs to be able to evaluate findings obtained on assessment and intervene
appropriately when these findings suggest underlying pathology.
In addition, this module assists the student in recognizing “normal” findings and
differentiating them from abnormal findings. Anticipatory guidance with regard to
feeding, daily routines and the characteristics of stools is addressed. As well, this
will aid the student to provide nursing care for the mother and newborn utilizing
nursing care plan as a teaching tool.
Moreover, the character of being a Canossian Nightingale must be developed in
delivering health care to establish a compassionate environment by providing
emotional, psychological, and spiritual support to pregnant mother and her family.
Also, the application of nursing process to plan and provide postpartum care.

Further, this module should not substitute the actual learning experience, however,
due to Covid 19 pandemic, this is provided to create continuous learning and meet
your learning needs.

Desired Learning Outcome: at the end of a 7-hour virtual learning exposure, you are
expected to:

1. Utilize the nursing process

2. Perform a holistic assessment based on the scenario given
3. Apply bioethical moral principles, core values and standards of patient care
4. Document the care rendered
I. Nursing Care with A Family with A Newborn: Immediate Care of the Newborn
Immediate Care of the Newborn
A newborn, or neonate, is the term used to describe a child from birth to 28 days old.
What are the four (4) time-bound interventions involved in EENC?

At the heart of the protocol are four (4) time-bound interventions:

1) immediate and thorough drying,

2) early skin-to-skin contact followed by,
3) properly timed clamping and cutting of the cord after 1 to 3 minutes, and
4) non-separation of the newborn from the mother for early breastfeeding initiation and rooming-
in.

What do these four (4) time-bound interventions do to the newborn?

1) Immediate and thorough drying of the newborn prevents hypothermia which is extremely
important to newborn survival
2) Keeping the mother and baby in uninterrupted skin-to-skin contact prevents hypothermia,
hypoglycemia, and sepsis, increases colonization with protective bacterial flora and
improved breastfeeding initiation and exclusivity
3) Properly timed cord clamping and cutting until the umbilical cord pulsation stops decreases
anemia in one out of every seven term babies and one out of every three preterm babies. It
also prevents brain (intraventricular) hemorrhage in one of two preterm babies.
4) Breastfeeding initiation within the first hour of life prevents an estimated 19.1% of all
neonatal deaths.

Apgar Score for Newborn Health Assessment

The Apgar score is a simple method of quickly assessing the health and vital signs of a
newborn baby after delivery. It was created by Dr. Virginia Apgar in 1952.

The five criteria assessed in the APGAR score are:

A – Appearance (Skin Color)
P – Pulse (Heart Rate)
G – Grimace (Reflex Irritability/Response)
A – Activity (Muscle Tone)
R – Respiration (Breathing Ability)

Appearance (Color)
All infants appear cyanotic at the moment of birth. They grow pink with or shortly after the first
breath, which makes the color of newborns correspond to how well they are breathing.
Acrocyanosis (cyanosis of the hands and feet) is so common in newborns that a score of 1 in
this category can be thought of as normal.

Pulse (Heart Rate)

Auscultating a newborn heart with a stethoscope is the best way to determine heart rate;
however, heart rate also may be obtained by observing and counting the pulsations of the cord
at the abdomen if the cord is still uncut. Once the cord has been cut and clamped, a pulse may
often be palpated by placing an index finger and thumb at the base of the cord.

Grimace (Reflex Irritability)

One of two possible cues is used to evaluate reflex irritability in a newborn: response to a
suction catheter in the nostrils or response to having the soles of the feet slapped. A good
response to these actions would be vigorous crying or a strong facial grimace. A baby whose
mother was heavily sedated will probably demonstrate a low score in this category.

Activity (Muscle Tone)

Mature newborns hold their extremities tightly flexed, simulating their intrauterine position.
Muscle tone is tested by observing their resistance to any effort to extend their extremities. Poor
muscle tone is observed when the infant shows no flexion of the arms and legs and extremities
“flop” back to the mattress when manipulated or flexed.

Respiration (Respiratory Effort)

Respirations are counted by watching respiratory movements. A mature newborn usually
cries and aerates the lungs spontaneously at about 30 seconds after birth. By 1 minute, he or
she is maintaining regular, although rapid, respirations. A depressed respiratory effort might be
anticipated in a newborn whose mother received large amounts of analgesia or a general
anesthetic during labor or birth.
Apgar Scoring

At 1 minute and 5 minutes after birth, newborns are observed and rated according to an
Apgar score, an assessment scale used as a standard since 1958 (Apgar et al., 1958).

How does the Apgar score work?

The Apgar scoring system is divided into five categories. Each category receives a score of 0
to 2 points. At most, a child will receive an overall score of 10. However, a baby rarely scores a
10 in the first few moments of life. This is because most babies have blue hands or feet
immediately after birth.

A: Activity/muscle tone
0 points: limp or floppy
1 point: limbs flexed
2 points: active movement

P: Pulse/heart rate
0 points: absent
1 point: less than 100 beats per minute
2 points: greater than 100 beats per minute

G: Grimace (response to stimulation, such as suctioning the baby’s nose)

0 points: absent
1 point: facial movement/grimace with stimulation
2 points: cough or sneeze, cry, and withdrawal of foot with stimulation

A: Appearance (color)
0 points: blue, bluish-gray, or pale all over
1 point: body pink but extremities blue
2 points: pink all over
R: Respiration/breathing
0 points: absent
1 point: irregular, weak crying
2 points: good, strong cry

As shown in Table above, heart rate, respiratory effort, muscle tone, reflex irritability, and
color of the infant are each rated 0, 1, or 2; the five scores are then added.
A newborn whose total score is less than 4 is in serious danger of respiratory or
cardiovascular failure and needs resuscitation. A score of 4 to 6 means that the infant’s
condition is guarded, and the baby may need clearing of the airway and supplementary oxygen.
A score of 7 to 10 indicates that the infant scored as high as 70% to 90% of all infants at 1 to 5
minutes after birth or is adjusting well to extrauterine life (10 is the highest score possible).
The Apgar score is repeated every additional 5 minutes, until a minimum score of 7 is
reached. The Apgar score standardizes infant assessment at birth and serves as a baseline for
future evaluations. There is a high correlation between low 5-minute Apgar scores and
neurologic illness (Harrington et al., 2007). The following points should be considered in
obtaining an Apgar rating.

Immediate Care of the Newborn

Definition: Early management of the newborn in the delivery room or in the Nursery few minutes
or soon after birth

Objective: Demonstrate the ability to perform/render Essential Immediate Newborn Care and
identify any deviations and make proper referral.

Purpose:
1. To establish, maintain and support respirations.
2. To provide warmth and prevent hypothermia.
3. To ensure safety, prevent injury and infection.
4. To identify actual or potential problems that may require immediate attention.

Equipment:
 2 warm towels or blankets
 Bonnet
 Sterile cord clamp
 2 tuberculin syringes
 2 Filter needle
 Sterile forceps
 Sterile scissors
 Name tag
 Hep B vaccine
 Vit K ampule
 Eye ointment (Erythromycin or Tetracycline ointment)
 Weighing scale
 Tape measure
 Stethoscope
 Cotton balls and alcohol
 Baby’s dress and blanket
 Diaper or disposable diaper

PROCEDURE
1. As the baby is born, place in a prone position
on the mother’s abdomen/chest
2. Do immediate and thorough drying using a
clean dry cloth/towel and do quick check of the
Newborn’s breathing (APGAR score)
3. Dry the baby by wiping the following:
3.1 Face
3.2 Eyes
3.3 Head
3.4 Front/Back
3.5 Arms/legs
4. Removes wet cloth/towel
5. Facilitates skin to skin contact (60-90 minutes)
and cover the baby’s back with a dry blanket
and head with bonnet
6. Remove the first of gloves used during delivery 
6.1 Clamp the cord pulsations have stopped
(typically
at 1-3 minutes). Do not milk the cord
towards the newborn
6.2 Put plastic clamp or tie with sterile
RATIONALE
 To facilitate drainage of
secretions (placing in prone
position)
 Drying the baby with warm
towels or cloths, while being
placed on the mother's abdomen
or in her arms. This mother-child
skin-to-skin contact is important
to maintain the baby's
temperature, encourage bonding
and expose the baby to the
mother's skin bacteria.
 Checking the breathing to ensure
lung expansion and take the 1st
breath
 Taking measures to maintain
body temperature, to ensure no
metabolic problems associated
with exposure to the cold arise.
 The baby's overall condition is
recorded at 1 minute and at 5
minutes after birth using the
Apgar Score.
Clamping and cutting the
umbilical cord with sterile
instruments, thoroughly
decontaminated by sterilization.
This is of utmost importance for
the prevention of infections.
 instrument
6.3 Cut between ties with sterile instrument
6.4 Observe for oozing blood
Note: Do not apply any substance to the stump
Do not bind or bandage the stump
Leave stump uncovered
7. Encourages and provides breastfeeding  Putting the baby to the breast as
support early as possible. Early
7.1 Observe Newborn for feeding cues suckling/breast-feeding should
(opening of the mouth, tonguing, licking, be encouraged, within the first
routing) hour after birth and of nipple
7.2 Counsel mother on positioning and stimulation by the baby may
attachment influence uterine contractions
and postpartum blood loss but
according to the WHO, this
should be investigated.
8. After 60-90 minutes, Applies CREDE’s  An antibiotic or few drops of
prophylaxis on the eye silver nitrate solution is usually
placed into the eyes to prevent
infection from any harmful
organisms that the baby may
have had contact with during
delivery (e.g. maternal STDs ).
9. Give Vitamin K prophylaxis.  Vitamin K is also administered to
prevent hemorrhagic disease of
the newborn.
10. Injects Hepatitis B vaccine.  Hepatitis B vaccine is needed to
inject to develop antibodies to
prevent the disease.
11. Administers BCG intradermally at the  BCG vaccine is needed to inject
intradermally to fight PTB.
12. Takes anthropometric measurements  To serve as baseline data for
including: health care provider.
12.1 Weight
12.2 Height
12.3 Head circumference
12.4 Chest circumference
12.5 Abdominal circumference
13. Perform and interpret APGAR scoring (After 5  The baby's overall condition is
minutes) recorded at 1 minute and at 5
minutes after birth using the
Apgar Score.
14. Take vital signs  To assess the fetal well-being.
15. Wash hands.  Reduces transmission of
microorganisms.
16. Document the results.  To serve as baseline data for
17. Reports any signs of deviation/abnormality to health care provider
the pediatrician
18. Bring and place newborn with her mother to  This mother-child skin-to-skin
 breastfeed and maintain skin to skin contact
and bonding.
contact is important to maintain
the baby's temperature,
encourage bonding and expose
the baby to the mother's skin
bacteria.

Reference:
1. Pilliteri, Adele, (2010). Maternal and child Health Nursing: Care of the Childbearing and
Child Rearing Family (6th ed). Philadelphia: Lippincott Williams and Wilkins.
2. Berman, Audrey, Shirley Snyder, Barbara Kozier and Glenora Erb, (2008).
Fundamentals of Nursing: Concepts, Process and Practice, (8th ed). New Jersey:
Pearson Prentice Hall
3. Castro, Ruth A. and Padilla, Ma. Teresa C., (2011). Clinical Experience and Checklist of
Midwifery Procedures. Philippines: Educational Publishing House.
4. https://www.youtube.com/watch?v=cgFRkfpXXH4
5. https://www.youtube.com/watch?v=cQKaTCMFjwc
6. https://www.youtube.com/watch?v=fz3_HDhj0X8&t=1003s
7. https://www.hon.ch/Dossier/MotherChild/birth/
immediatecare_neonate.html#:~:text=Immediate%20care%20involves%3A,to%20the
%20mother's%20skin%20bacteria.
8. https://www.youtube.com/watch?v=TXhEp4aCAmM
9. https://www.youtube.com/watch?v=cracmPo3iYo
10. https://www.youtube.com/watch?v=pn47nfIcvxU

Learning Task 1: Nursing Care with A Family with A Newborn: Immediate Newborn Care

Instructions:
1. All questions apply to this activity pertains to the concepts and theories
discussed. Your responses should be detailed and direct to the point. When
asked to provide several answers, list them in order of priority or
significance.
2. Please submit on or before _______, 2021 thru Google Classroom.
You’re on your way!
Short Answer
Supply the missing term of the information requested.
1. __________________________ or _________________________ ointment is used to
prevent ophthalmia neonatorum. It should be instilled into the newborn’s
_____________________ from the __________________ to the
_______________________.
2. ______________________________ is administered intramuscularly to newborns to
prevent hemorrhage. It is administered in a dose of ____________________ using a
___________________ gauge, _________________ inch needle.
3. The infant is vulnerable to heat instability and loses heat readily through four separate
mechanisms ____________________, ___________________, ___________________
and ___________________.
4. The average respiratory rate for the neonate is _________ breaths per minutes.
5. List the 5 criteria described Apgar that are used as a basis to evaluate the newborn’s
well-being.
_______________________, ____________________, _______________________,
____________________________, and ________________________.

Learning Task 2: Nursing Care with A Family With A Newborn: Critical Thinking

Instructions:
1. All questions apply to this activity pertains to the concepts and theories
discussed. Your responses should be detailed and direct to the point. When
asked to provide several answers, list them in order of priority or
significance.
2. Please submit on or before _______, 2021 thru Google Classroom.

Case Study
Mrs. Zuniga delivered (vaginally) a baby girl today. Baby girl Zuniga was evaluated to be 37
weeks gestation and weigh 3300 g. Mrs. Zuniga plans to breastfeed her baby. You are assigned
as the nurse to take care of her and her baby.
1. Shortly after delivery, Baby girl Zuniga at 1 minute after birth:
Heart rate – 160 beats per minute
Respiratory effort – good, crying vigorously
Muscle tone – active movement, well flexed
Reflex irritability – cries with stimulus to soles of feet
Color – body pink, feet, and hands cyanotic

Score: _______________________________
 Interpretation: ________________________

2. Within 12 hours after birth the newborn passes a sticky black stool. Explain why this
should not alarm you.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________.
3. On the day of discharge, baby girl Zuniga appears to have yellow skin and sclera. What
laboratory test might be ordered at this time. What would be indicated if the results are
higher than normal values?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
________________________.

4. Formulate a nursing care plan that will focus on nursing care for Baby girl Zuniga who
has yellowish discoloration of the skin and sclera.

Nursing Care Plan:

Fill in the appropriate elements of the care plan for this client.

PLANNING
ASSESSMENT NURSING GOAL / EVALUATION
NURSING
EXPECTED RATIONALE
DIAGNOSIS INTERVENTIONS
OUTCOME
Reflection Point:
Having been drawn with concepts of maternal and child nursing, how
would you, as a Canossian Nightingale anticipate the clinical exposure
in the Delivery Room / Neonatal Intensive Care Unit (NICU.

_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________

“…observation and experience will teach us ways to maintain or to bring back the
state of health.”
Florence Nightingale

You just finished Module 8.

“Every accomplishment starts with the decision to

try.”
– Unknown