NCM 107:

RLE MODULE 1F

NEWBORN DELIVERY AND ASSESSMENT OF

NEWBORN

SECTION F -Group 4:

Mr. Mar, Jhuan Laeus Miguel L.- Leader

Members:
Pizarras, Christlynee Alexa
Pajo, Keziah Marie Denz
Pajaron, Faith Colleen
Biscocho, Ma. Aloysia Victoria
Marquez, Micolo Joaquin
Mar, Jhuan Laeus Miguel
Salazar, Kim Annais

Facilitator: Ms. Nikki Rae Cayanan

Date Submitted: September 21, 2022
 TABLE OF CONTENTS
TITLE PAGE

Learning Outcomes for Newborn Delivery

CLO# 1: Define the key terms related to Newborn Delivery.

CLO# 2: Cite the importance of handle, assist and cord care during
Newborn Delivery.
CLO# 3: Explain the scientific principles involved in Newborn Delivery.
CLO# 4: List guidelines in Newborn Delivery.
CLO# 5: Enumerate and discuss nursing responsibilities before,
during and after Newborn Delivery.
CLO# 6: Discuss Unang-Yakap (First Embrace).
CLO# 7: Enumerate the materials needed in Newborn Delivery.
CLO# 8: Document outcome of Newborn Delivery and pertinent data
CLO# 9: Demonstrate beginning skills as Handle, Assist and Cord
Care of the in Newborn Delivery.
CLO# 10: Utilize the knowledge on Newborn Delivery in providing
care to a client using a clinical-case scenario

Learning Outcomes for Newborn Assessment

CLO# 11: Define the key terms related to assessment of the

newborn.
CLO# 12: Utilize the different tools in assessing the newborn.
CLO# 13: Discuss the importance of assessing the newborn.
CLO# 14: Discuss the major points of Newborn Screening Act of
2004.
CLO# 15: Explain the principle involved in assessment of the
newborn.
CLO# 16: List guidelines in assessing the newborn.
CLO# 17: Enumerate and discuss nursing responsibilities before,
during and after assessment of the newborn.
CLO# 18: Recognize the different materials and supplies used in
assessing the newborn and its uses.
CLO# 19: Document client responses and outcomes after assessment
of newborn.
CLO# 20: Demonstrate beginning skills integrating the CDUCN Core
Values in assessing the newborn
CLO# 21: Utilize the knowledge in Assessment of Newborn in
providing care to a client using a clinical-case scenario.

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 NEWBORN DELIVERY AND ASSESSMENT OF
NEWBORN

LEARNING OUTCOMES:
After 9 hours of varied online class activities, the level II nursing students will
be able to:

CLO# 1: Define the key terms related to Newborn Delivery.

CLO# 2: Cite the importance of handle, assist and cord care during Newborn Delivery.
CLO# 3: Explain the scientific principles involved in Newborn Delivery.
CLO# 4: List guidelines in Newborn Delivery.
CLO# 5: Enumerate and discuss nursing responsibilities before, during and after Newborn
Delivery.
CLO# 6: Discuss Unang-Yakap (First Embrace).
CLO# 7: Enumerate the materials needed in Newborn Delivery.
CLO# 8: Document outcome of Newborn Delivery and pertinent data
CLO# 9: Demonstrate beginning skills as Handle, Assist and Cord Care of the in Newborn
Delivery.
CLO# 10: Utilize the knowledge on Newborn Delivery in providing care to a client using a
clinical-case scenario
CLO# 11: Define the key terms related to assessment of the newborn.
CLO# 12: Utilize the different tools in assessing the newborn.
CLO# 13: Discuss the importance of assessing the newborn.
CLO# 14: Discuss the major points of Newborn Screening Act of 2004.
CLO# 15: Explain the principle involved in assessment of the newborn.
CLO# 16: List guidelines in assessing the newborn.
CLO# 17: Enumerate and discuss nursing responsibilities before, during and after assessment of
the newborn.
CLO# 18: Recognize the different materials and supplies used in assessing the newborn and its
uses.
CLO# 19: Document client responses and outcomes after assessment of newborn.
CLO# 20: Demonstrate beginning skills integrating the CDUCN Core Values in assessing the
newborn
CLO# 21: Utilize the knowledge in Assessment of Newborn in providing care to a client using a
clinical-case scenario.

3
 CLO# 1: Define the key terms related to Newborn Delivery.

1. Apnea
- Apnea is defined as cessation of breathing for at least 10 seconds

https://www.sleepcareonline.com/articles/what-is-the-main-cause-of-sleep-apnea/

2. Asphyxia
- a lack of oxygen or excess of carbon dioxide in the body that results in unconsciousness
and often death and is usually caused by interruption of breathing or inadequate oxygen
supply

https://www.thecplawyer.com/brain-injury/asphyxia-oxygen-deprivation/

3. Assist
- provides immediate care to a newborn by ensuring airway clearance, taking
anthropometric measurements and evaluation of the baby’s extrauterine adaptation.

4
 https://www.verywellfamily.com/whos-who-in-the-delivery-room-2752947

4. cord care
- Cord care is how to care for your baby's umbilical cord stump.

https://raisingchildren.net.au/newborns/health-daily-care/hygiene-keeping-clean/umbilical
-care

5. cord coil
- Nuchal cord occurs when the umbilical cord becomes wrapped around the fetal neck
360 degrees.

https://ph.theasianparent.com/cord-around-the-neck-symptoms

5
6. duncan
- The expulsion of the placenta with presentation of the maternal rough side first, rather
than the usual fetal side of the placenta.
- The separation method involves detachment of the leading edge of the placenta, and
the entire organ slips down and out of the uterus sideways. Thus, the maternal side
descends after the Schultze method.

https://nurseinnursing.com/physiology-and-management-of-third-stage-of-labour/

7. dyspnea
- Shortness of breath. is often described as an intense tightening in the chest, air hunger,
difficulty breathing, breathlessness or a feeling of suffocation.

https://www.bmj.com/content/353/bmj.i2361

8. episiorrhaphy
- surgical repair of injury to the vulva by suturing.

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 https://obgynkey.com/episiotomy-2/

9. episiotomy
- surgical incision of the perineum to enlarge the vaginal opening for obstetrical purposes
during the birth process

https://en.wikipedia.org/wiki/Episiotomy

10. grunting
- to make a short, low sound instead of speaking, usually because of anger or pain

https://www.momjunction.com/articles/baby-grunting_00474792/

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11. handle
- provides assistance to the obstetrician during the delivery by serving the
needed instruments and by supporting the perineum.

https://medely.com/blog/example-labor-and-delivery-nurse-job-description/

12. hypothermia
- Hypothermia is a medical emergency that occurs when your body loses heat, causing a
dangerously low body temperature of ,36.5.

https://www.medicalnewstoday.com/articles/326569

13. immediate newborn care

- Newborn immediate care is the care given to the neonate after birth by qualified
personnel in the delivery room.

https://parenting.firstcry.com/articles/immediate-care-of-your-newborn-baby/

8
14. meconium staining
- Meconium is a thick, greenish-black substance. It forms before a baby is born. In the
womb, a baby swallows and digests the amniotic fluid. Then the intestines make
meconium.

https://library.med.utah.edu/nmw/mod2/Tutorial2/meconium_lobes.html

15. newborn delivery

- Childbirth, also known as labor and delivery, is the ending of pregnancy where one or more
babies exits the internal environment of the mother via vaginal delivery or Caesarean section.

https://en.wikipedia.org/wiki/Infant

16. ophthalmia neonatorum

- The definition of Ophthalmia Neonatorum (conjunctivitis of the newborn) is an eye
infection that occurs within the first 30 days of life. It is caught during birth by contact
with the mother's birth canal that is infected with a sexually-transmitted disease. The
infection may be bacterial, chlamydial or viral.

9
 https://en.wikipedia.org/wiki/Neonatal_conjunctivitis

17. oxytocin
- a pituitary octapeptide hormone C43H66N12O12S2 that stimulates especially the
contraction of uterine muscle and the secretion of milk

https://www.alilamedicalmedia.com/media/ac9f831a-08fb-11e3-a079-1d7f001df195-oxyto
cin-hormone

18. schultze
- a propellant of the smokeless powder type consisting essentially of nitrated pellets of
wood impregnated with barium nitrate and potassium nitrate
- The separation of the placenta from the uterine wall during labor; it begins at the
placental center and leads to an expulsion of the placenta after delivery of the baby.
Thus, the fetal side descends first, with the remainder following.

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 https://nurseinnursing.com/physiology-and-management-of-third-stage-of-labour/

19. still birth

- A stillbirth is the death of a baby in the womb after week 20 of the mother’s pregnancy.
As miscarriage is a loss of the baby prior to the 20th week of pregnancy.

https://www.queenslandfamilyandfertilitysupport.com/the-uncensored-experience-of-stillbi
rth/

20. suction
- a device (such as a pipe or fitting) used in a machine that operates by suction
- removal of material through the use of negative pressure, as in suctioning an operative
wound during and after surgery to remove exudates, or to remove secretions that the
patient cannot remove.

11
https://www.mybabysheartbeatbear.com/blogs/pregnancy/stop-suctioning-the-airway-of-a
-baby-at-birth

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CLO# 2: Cite the importance of handle, assist and cord care during
Newborn Delivery.
2.1 Handle
- Helps the doctor do episiorrhaphy. They are frequently in charge of collaborating
with physicians to create a customized birthing plan for each woman in order to
guarantee the safety of each delivery for both the mother and the child.
- Gives emotional support to the mother by advising her on how to bear down.
- Avoids perineal laceration by providing support while the baby is delivered.

2.2 Assist
- suctioning ensures the newborn's airway clearance
- Prevents bleeding by giving the infant vitamin K.
- Hepatitis B is prevented by delivering the Hepatitis B vaccination.
- Prevents hypothermia on the baby
2.3 Cord care
- It's critical to keep the cable clean and dry so it can come out naturally. Your infant
is at danger of infection if the umbilical cord stump is not adequately cared for.
- Cord care protects the infant's cord stump against infection. In rare cases, these
infections might penetrate the baby's body and cause serious or even fatal
disorders. It may also aid in the removal of the umbilical cord stump and the rapid
healing of the navel.

CLO# 3: Explain the scientific principles involved in Newborn

Delivery.

3.1 Anatomy and Physiology

- It is critical to understand the physiological markers of the mother's body in order
to guarantee a safe birth of the baby. Not only that, but also as well as the baby's
physiologic components and functions to assure the baby's safety before, during, and
after delivery Knowing the typical limits of vital signs is critical since the mother's heart
rate, blood pressure, temperature, and breathing rate may all fluctuate quickly before,
during, and after childbirth, and alterations in these can lead to issues that are
potentially detrimental to the baby.

3.2 Microbiology
- When aiding with a newborn's delivery, always remember to use asepsis
procedure. Remember that newborns are immunocompromised since they have not yet
built a robust immunity to environmental germs. As a result, as a nurse and a
healthcare worker, it is critical to maintain sterility when aiding with the delivery of a
newborn.

3.3 Safety and Security

- Provide the customer with privacy and comfort. As a healthcare practitioner, it is
our responsibility to ensure that the patient is not harmed throughout the birthing
process and to do all possible to make the patient's delivery experience good.

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3.4 Mathematics
- Following the delivery of a baby, many measures are obtained. This is done to
track their development and progress. The infant's weight, length, belly circumference,
and head circumference would all be measured. The unit of measurement may differ
depending on the equipment used, thus it is critical for the nurse to understand
measurement conversion procedures (e.g., pounds to kilograms, grams to kilograms,
and so on) in order to obtain correct and trustworthy data.

3.5 Physics
- When compared to adults, babies are less tolerant to temperature changes.
When caring for a newborn, thermoregulation is critical. To avoid hypothermia, it is
critical to balance heat production and heat loss in order to maintain a baby's normal
body temperature, especially in the initial few minutes following birth. Methods for
keeping newborns warm include: (1) rapid drying and warming using blankets and
skin-to-skin contact; and (2) skin-to-skin contact.

3.6 Pharmacology
- The birth of the infant involves several areas of pharmacology. These include, but
are not limited to, calculating the flow rate of an IV drip, delivering medicine to
maintain the mother's well-being, identifying drugs that may be supplied in the event
of difficulties, and so on. In addition, newborn children are given vitamin K and
Hepatitis B vaccines parenterally after birth. Vitamin K is necessary for blood clotting
and preventing major bleeding. Babies do not receive enough vitamin K from their
moms during pregnancy or nursing. They are at danger of developing Vitamin K
Deficiency Bleeding (VKDB) or Hemorrhagic Disease of the Newborn if they do not
acquire enough vitamin K. (HDN). Hepatitis B, on the other hand, is a virus that
primarily affects the liver, and most individuals who have it are asymptomatic. As a
result, it is given after delivery to prevent neonates from catching it from viral carriers,
as Hepatitis B infection can lead to serious liver disease (cirrhosis) or cancer in adults.

3.7 Time and Energy

- To minimize delays and to guarantee that the birthing process runs easily and
without issues, it is critical to prepare the materials, place the curtains, and set the
tools needed during delivery ahead of time.

3.8 Body Mechanics

- Because labor is a long and arduous procedure, proper body mechanics must be
followed to avoid exhaustion. Additionally, ensuring that the mother is in the proper
posture (lithotomy position) to encourage a safe and easy delivery.

3.9 Psychology
- Women must comprehend what is occurring to them before, during, and after
birth. Establishing rapport and creating a kind and welcome aura will help to alleviate
the patient's worry and uneasiness during the birthing process. To alleviate the
mother's fear and uneasiness, explain what to expect during the birthing process.

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CLO# 4: List guidelines in Newborn Delivery.

Handle
● Perform medical hand washing and surgical handwashing
before the procedure.
● Perform gowning and closed gloving aseptically.
● Arrange the instruments according to use.
● Observe aseptic technique as OB set and pack are
prepared.
● Observe sterility as gown and gloves are served to the
physician
● Drape the patient aseptically.
● Serve bandage scissors for episiotomy.
● Apply forward-upward thrust in supporting the perineum.
● Deliver anterior shoulder first followed by posterior shoulder.
● Call out time of birth.
● Suction mouth first followed by nose.
● Do not pull placenta as it is delivered.
● During episiorrhaphy, serve the round needle in suturing
delicate tissues and cutting needle in suturing the skin.
● Anticipate the needs of the physician all throughout the
procedure.
● Do after care.

Assist
● ​Do medical handwashing and open gloving prior to the
procedure.
● Suction secretions as needed.

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 ● Perform immediate newborn care fast but accurate and keep
the newborn thermoregulated.
● Apply eye prophylaxis from inner to outer canthus.
● The metal/plastic tip of the eye prophylaxis must not touch
the eye of the baby.
● In taking the head circumference, place the tape measure
above the eyebrows.
● In taking the chest circumference, place the tape measure
on the nipple line.
● In taking the abdominal girth, do not include the umbilical
Cord.
● Administer 0.05 mL or 0.5mg of vitamin K to preterm newborns and 0.1 mL or
1mg to term newborns.
● Administer vitamin K and Hep B vaccine on vastus lateralis
● Disinfect the site before injection.
● Take the first temperature rectally.
● In applying the diaper, keep the umbilical cord outside it.
● Never leave the newborn alone on the table or on high
surfaces.
● Ascertain the identity of the newborn before placing the
identification band.
Cord care
● Perform medical handwashing and open gloving prior to the
procedure.
● Suction secretion as needed.
● Do not pull the cord while performing the procedure.
● Direction of cord disinfection is from the cord base going up.
● Use different swab sticks for the base, umbilical cord and
stump.

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 ● Cut the cord in between the 2 clamps.
● Assess for the number of cord vessels.
● Do after care.
● Document the APGAR accurately.

CLO# 5: Enumerate and discuss nursing responsibilities before,

during and after Newborn Delivery.

Before
● Position patient in lithotomy position.
● Perform perineal care.
● Provide mask and cap to the patient.
● Explain procedure to the patient.
● Prepare necessary materials and arrange according to use.
● Apply sterile drapings on the mother.
● Teach patient on deep breathing exercises.
● Instruct patient on when to bear down.
During
Handle
● Coach mother in bearing down.
● Serve instruments to the physician.
● Support the perineum using forward-upward thrust.
● Deliver anterior shoulder followed by posterior shoulder (performed by physician
but be prepared to perform this step if there is no physician)
● Call out time of birth (physician)
● Endorse the newborn to the cord care nurse.
● Deliver the placenta (physician)
● Take the blood pressure of the patient (circulating nurse).
● Assist the physician during episiorrhaphy.

Cord Care
● Perform APGAR scoring.
● Ensure that the newborn is thermoregulated by changing the wet flannel and
performing the procedure under a goose neck lamp.
● Disinfect the umbilical cord.
● Clamp and cut the cord.

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 ● Determine the number of vessels in the cord.
● Endorse the baby to the assist nurse.
Assist
● Suction secretions as needed.
● Apply eye prophylaxis.
● Take anthropometric measurements.
● Administer vitamin K and Hepatitis B.
● Take temperature rectally.
● Apply diapers.
● Apply identification band.
● Assess the newborn using Ballard’s Assessment

After
● encourage mother-infant bonding by letting the mother hold her baby by placing
the infant on the mother’s naked abdomen covered with warm blanket and cap to
conserve heat
● Do after care.
● Document assessment findings.
● Monitor vital signs of the mother and the newborn.

CLO# 6: Discuss Unang-Yakap (First Embrace).

Unang yakap is the campaign to spread the use of the Essential Newborn Care
(ENC) Protocol Department of Health. It highlights the necessity of breastfeeding for the
first 60 to 90 minutes since the release of the protein- and nutrient-rich colostrum occurs in
the early stages of nursing.

● Purpose
-protects newborn babies from infections through the release of the protein and
nutrient-rich colostrum.

● Steps of Essential Newborn Care

I.) immediate and thorough drying
II.) early skin-to-skin contact
III.) properly-timed clamping and cutting of the cord after 1 to 3
minutes
IV.) non-separation of the newborn from the mother for early
breastfeeding initiation and rooming-in

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 ● Benefits of proper cord clamping
-Proper cord clamping and cutting prevents anemia and protects against brain
hemorrhage in premature newborns. This means waiting for the cord pulsations to
stop (between 1 to 3 minutes)

● Benefits of skin-to-skin contact

-Early skin-to-skin contact between mother and newborn and delayed
washing for at least six hours prevents hypothermia, infection and hypoglycemia

CLO# 7: Enumerate the materials needed in Newborn Delivery.

1. Amniotic Hook

The amniotic hook is shaped similarly to a crochet hook, but isn’t used for anything that
involves yarn. This hook is used to rupture your membranes during the beginning of labor
if it doesn’t happen naturally. This is more commonly referred to as “breaking your water.”

2. Anesthesia workstation / Boyle’s apparatus

The anesthetic machine or anesthesia machine or Boyle’s machine is used by physician

anesthesiologists to support the administration of anesthesia. They provide an accurate and
continuous supply of medical gases as oxygen and nitrous oxide, mixed with an accurate
concentration of anesthetic vapour such as isoflurane and deliver this to the patient at safe
pressure and flow.

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 3. Electrosurgical unit / Cautery machine

An Electrosurgical unit is used in surgery to cut, coagulate, or otherwise alter tissue, often to
limit the amount of blood flow to an area and increase visibility during a surgery. This equipment
is crucial to cauterizing and minimizing blood loss during surgery.

4. Forceps

Forceps function much like tongs, but can be used to shift the baby’s position or help to
guide the head. If your labor has been long and tiring or your baby is becoming
distressed, forceps can assist in the birth as an alternative method to using a vacuum (or
a ventouse.)

5. Hemostat

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A hemostat closely resembles scissors, although they aren’t meant to be sharp. They don’t have
blades as scissors do. The hemostat is used for a multitude of different things, but most
importantly, it holds the umbilical cord before its cut

6. Kelly Pad:

An obstetrical device used to funnel blood to a collection device in order to help detect
postpartum emmorage of the mother; Mainly used in hospitals for puerperal women

7. Laparoscopic Sponges

Laparoscopic sponges is used in case you have excessive amounts of bleeding, which is
actually common throughout the delivery.They look similar to gauze pads, but they are able to
absorb more liquid, making them ideal for surgical procedures including delivery.

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8. Noelle Birthing Simulator:

Simulator system designed to simulate the complete birthing process

9. OB pack (with 2 covers):

A sterile gynecology surgical pack

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 10. Operating Table/Surgical Table:

Equipment which is a necessities for a hospital. For performing a surgery operating table is
important, so that the patient on whom the surgery is to be performed can be placed on the
table.

11. Pail or Bucket:

a roughly cylindrical open container, typically made of metal or plastic, with a handle,
used to hold and carry liquids or other material.

12. Placental bowl:

Used to store mother’s placenta postpartum

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 13. Plastic Ampules of lidocaine:

Used as anesthetic create numbness or loss of feeling for patients having certain medical
procedures

14. Scissors

This one is shaped differently, with more curves to the blades. Although different, these
scissors are typically used to cut the umbilical cord by your spouse or doctor.

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 15. Speculum

The speculum is typically used during the beginning of your labor to gauge your progress. It’s a
hinged instrument that is closed upon insertion and then opened so your doctor can see further
into your vagina.

16. Sterilizer / Autoclave

Hospital sterilizers kill all forms of microbial life including fungus, bacteria, viruses, spores, and
all other entities present on surgical tools and other medical items. Usually sterilization process
is done by bringing an instrument to a high temperature with steam, dry heat, or boiling liquid.

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 17. Sterile gloves:

A type of disposable glove that are devoid of germs and free from all microorganisms

18. Suction apparatus / Suction machine / Vacuum apparatus

Suction apparatus is a medical device used to remove different types of secretions

including liquid or gaseous secretions from the body cavity. It is based on the principle of
vacuuming. Suction may be used to clear the airway of blood, saliva, vomit, or other
secretions so that a patient may breathe properly.

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 19. Surgical lights / OT Light

A surgical light which is also called as an operating light is a medical equipment which helps
medical personnel during a surgery by illuminating on a local area of the patient. During the
surgery the intensity from each dome should be uniform. The lights used for surgery should be
shadow less.

20. Sutures
sutures are used to stitch up a cut or torn tissue. You may not notice sutures sitting along with
the other instruments, but they are by far one of the most important tools in the delivery room.

21. 10 cc Syringe:

A syringe with a 10 mL capacity, commonly used for intravenous injections

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 CLO# 8: Document outcome of Newborn Delivery and pertinent data.

Before Delivery:

● Ballard score - is commonly used to determine gestational age. Here’s how it works:
● Scores are given for 6 physical and 6 nerve and muscle development
(neuromuscular) signs of maturity. The scores for each may range from -1 to 5.
● The scores are added together to determine the baby’s gestational age. The total
score may range from -10 to 50.
● Premature babies have low scores. Babies born late have high scores.

● Detection of fetal heart using fetal doppler -A fetal Doppler is a test that uses sound
waves to check your baby’s heartbeat. It’s a type of ultrasound that uses a handheld
device to detect changes in movement that are translated as sound.

During Delivery:

● Date and Time of Delivery -It is crucial to record the precise day and hour of delivery
since it allows for medical records monitoring.
● Biological sex of the newborn - It is important for the medical staff to determine the
baby's gender after noting the time and date of delivery.
● Blood pressure of mother after placental expulsion - Some pregnant women
experience elevated blood pressure. Due to this, there may be pregnancy-related issues
for both the mother and the unborn child.
● Mechanism of placental expulsion - It's crucial to understand how the placenta
should naturally pass through the vagina.
● Time of placental expulsion - It is necessary to keep track of time when the placenta
comes out of the birth canal after childbirth.

After Delivery:

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● Documentation of vital signs
● Documentation of weight, length, and head circumference
● Documentation of how the baby is small or large for gestational age using Growth Charts
● O2 Inhalation per nasal cannula
● Anthropometric measurements
● APGAR Score
● Venoclysis
● Aseptically Inserted Heplock
● Suctioned Secretions PRN
● Bag Mask/Intubation
● Check and Document for Appearance
● Check Cry and reflexes
● Check and document for Congenital malformations
● Record the exact time on cord clamping and cutting done aseptically
● In order to start breastfeeding and provide kangaroo care early, the mother and infant
should not be separated.

CLO# 10: Utilize the knowledge on Newborn Delivery in providing

care to a client using a clinical-case scenario.

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 CLO# 11: Define the key terms related to assessment of the
newborn.

Assessment of Newborn

1. Acrocyanosis-

- Acrocyanosis means bluish discoloration of the extremities due to the decreased amount
of oxygen delivered to the peripheral part. It is a functional peripheral arterial disease, is
a persistent, painless bluish discoloration of both hands and, less commonly, of both feet,
caused by spasm of the small blood vessels within the skin, usually in response to cold or
emotional stress.

2. Appropriate for Gestational Age

- Gestation is the period of time between conception and birth. During this time, the baby
grows and develops inside the mother's womb. If the baby's gestational age findings after
birth match the calendar age, the baby is said to be appropriate for gestational age
(AGA). AGA babies have lower rates of problems and death than babies that are small or
large for their gestational age.

3. APGAR Scoring

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- Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute
score determines how well the baby tolerated the birthing process. The 5-minute score
tells the health care provider how well the baby is doing outside the mother's womb. The
Apgar test is done by a doctor, midwife, or nurse. The provider examines the baby's:
breathing effort, heart rate, muscle tone, reflexes and skin color.

4. Ballard’s assessment chart

- The Ballard Maturational Assessment, Ballard Score, or Ballard Scale is a commonly used
technique of gestational age assessment. A baby's gestational age often can be closely
estimated using this examination. The Dubowitz/Ballard Examination evaluates a baby's

appearance, skin tex ture, motor function,

and reflexes.

5. Caput succedaneum

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- It is the swelling of the scalp in a newborn. It is most often brought on by pressure from
the uterus or vaginal wall during a head-first (vertex) delivery.

6. Central cyanosis

- The term “central cyanosis” refers to cyanosis found on the “central” parts of the body
which involves the mouth, the head, and the torso. Central cyanosis is never normal in
the newborn period, and is almost always linked to a lower amount of oxygen in the
blood. It could be due to the problems of the heart, the lungs or the blood.

7. Cephalohematoma

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- Cephalohematoma is blood that collects between a newborn’s scalp and skull. Hematoma
means blood that pools outside the blood vessels. Cephalo refers to the head. This kind
of birth injury occurs when pressure on a baby’s head ruptures blood vessels in the scalp.

8. Cyanosis

- Cyanosis refers to a bluish-purple hue to the skin. It is most easily seen where the skin is
thin, such as the lips, mouth, earlobes and fingernails. Cyanosis indicates there may be
decreased oxygen attached to red blood cells in the bloodstream. It may suggest a
problem with the lungs or heart.

9. Erythema toxicum

- It is a blotchy red rash with small bumps that can be filled with fluid. Although the fluid
might look like pus, there is no infection indiciated. Erythema toxicum is also known as

33
 erythema toxicum neonatorum (ETN) which does not cause any symptoms and goes
away on its own, therefore no treatment is requied.

10. Full-term

- A full-term pregnancy lasts between 39 weeks, 0 days and 40 weeks, 6 days. This is 1
week before your due date to 1 week after your due date. Every week of pregnancy
counts for your baby’s health. Like for instance, when your baby’s brain and lungs are still
developing in the last weeks of pregnancy.

11. Hemangioma

- A hemangioma is a common vascular birthmark, made of extra blood vessels in the skin.
It is a benign growth and the exact cause is not detected. It is also not inherited, but
others in the family may also have had them.

12. Hemorrhage

34
- Hemorrhage or also called as bleeding, is the name used to describe blood loss. It can
refer to blood loss inside the body, called internal bleeding, or to blood loss outside of the
body, called external bleeding. Blood loss can occur in almost any area of the body.
Internal bleeding occurs when blood leaks out through a damaged blood vessel or organ.
External bleeding happens when blood exits through a break in the skin.

13. Kangaroo care

- Kangaroo care is a method of holding a baby that involves skin-to-skin contact. The baby,
who is typically naked except for a diaper, is placed in an upright position against a
parent’s bare chest. Both mothers and fathers can do kangaroo care. It’s often used with
premature infants while they are still in the hospital.

14. Lanugo

35
- Lanugo is a type of body hair a fetus develops in the womb (uterus) for protection and
warmth. Babies typically shed lanugo before birth; however, some babies don’t shed it for
several weeks after birth.

15. Large for Gestational Age

- Large for gestational age (LGA) refers to a fetus or infant who is larger than expected for
their age and gender. It can also include infants with a birth weight above the 90th
percentile. The LGA measurement is based on the estimated gestational age of the fetus
or infant.

16. Low birth weight

36
- Low birth weight is a term used to describe babies who are born weighing less than 5
poundsm 8 ounces (2,500 grams). An average newborn usually weighs about 8 pounds. A
low-birth-weight baby may be healthy even though he or she is small.

17. Meconium

- Meconium is the first feces, or stool, of the newborn. Meconium aspiration syndrome
occurs when a newborn breathes a mixture of meconium and amniotic fluid into the lungs
around the time of delivery.

18. Milia

- Milia are tiny white bumps (pimples or cysts) on your skin. They most often happen on
infants' faces. But anyone can get them on any part of the body. You may hear milia (one
is a milium) referred to as milk spots or oil seeds. It's a common blemish that affects 40%
to 50% of newborns.

19. Mongolian Spot

37
- Mongolian blue spots are flat bluish to bluish-gray skin markings commonly appearing at
birth or shortly thereafter. They appear commonly at the base of the spine, on the
buttocks and back and also can appear on the shoulders. Mongolian spots are benign and
are not associated with any conditions or illnesses.

20. Natal Tooth

- Natal teeth are teeth that are already present at birth. They are different from neonatal
teeth, which grow in during the first 30 days after birth. Both baby teeth (deciduous or
milk teeth) and permanent teeth have fairly well-defined times of eruption.

21. Neonatal period

38
- The neonatal period is the first 4 weeks of a child's life. It is a time when changes are
very rapid. Many critical events can occur in this period: Feeding patterns are established.
It's a time of rapid change and development where patterns for infancy, like feeding and
bonding, are developed. It's also the period when there are the most risk for post-birth
complications or when birth defects or congenital conditions may first be detected.

22. Neonate

- A neonate is a baby who is 4 weeks old or younger. A neonate is also called a newborn.
The neonatal period is the first 4 weeks of a child's life. It is a time when changes are
very rapid. Many critical events can occur in this period such as feeding patterns are
established, bonding between parents and infant begin, the risk for infections that may
become more serious are higher, and many birth or congenital defects are first noted.

23. Nevus flammeus

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- Nevus flammeus or port-wine stain is a capillary malformation presenting as a pink or red
path on a newborn’s kin. It is a congenital skin condition that can affect any part of the
body and persists throughout life.

24. Pathologic jaundice

- It is the most serious type of jaundice. It occurs within 24 hours after birth, and is
characterized by a rapid rise in a baby;s bilirubin levels. The most likely cause is blood
incompatability or liver disease. Prompt medical attention is necessary, and blood
transfusions may be required.

25. Physiologic jaundice

40
- Physiologic jaundice is caused by a combination of increased bilirubin production
secondary to accelerated destruction of erythrocytes, decreased excretory capacity
secondary to low levels of ligandin in hepatocytes, and low activity of the
bilirubin-conjugating enzyme uridine diphosphoglucuronyltransferase (UDPGT).

26. Post-term

- A postterm pregnancy is one that extends beyond 42 weeks (294 days) from the first day
of the last menstrual period; as many as 10 percent of pregnancies are postterm. ● The
chance of postterm pregnancy is higher in first pregnancies and especially in pregnant
individuals who have had a postterm pregnancy in the past.

27. Pre-term

41
- Preterm birth is when a baby is born too early, before 37 weeks of pregnancy have been
completed. Labor is the process your body goes through to give birth to your baby.
Preterm labor can lead to premature birth.

28. Prophylaxis

- Prophylaxis is given to newborns to prevent eye infections through sexually transmitted

diseases. After birth, your baby’s nurse will place medicated eye ointment in your baby’s
eyes to prevent potential infection or blindness from gonorrhea and chlamydia infections.

29. Pseudomenstraution

- Newborn girls may have a small amount of vaginal discharge – a thick, white mucus that
may sometimes be tinged with blood. This is called pseudomenstruation and happens
because your baby is no longer getting your hormones through the placenta. It's perfectly
normal.

30. Silverman Anderson Index

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- The Silverman-Andersen Retraction Score (SAs) is used to assess severity of respiratory
distress in newborn and preterm infants without respiratory support. The score comprises
4 inspiratory categories of movements (thoraco-abdominal, intercostal, xiphoid, and chin
movements) and one expiratory category (grunting).

31. Small for Gestational Age

- Small for gestational age is a term used to describe a baby who is smaller than the usual
amount for the number of weeks of pregnancy. SGA babies usually have birthweights
below the 10th percentile for babies of the same gestational age. Many babies normally
weigh more than 5 pounds, 13 ounces by the 37th week of pregnancy. Babies born
weighing less than 5 pounds, 8 ounces are considered low birth weight.

32. Subconjunctival hemorrhage

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- A subconjunctival hemorrhage occurs when a tiny blood vessel breaks just underneath
the clear surface of your eye (conjunctiva). In many ways, it is just like having a bruise on
your skin. The conjunctiva cannot absorb blood very quickly, so the blood gets trapped. It
can be seen as scary but it is actually harmless.

33. Transitional stool

- Transitional stools are the loose, yellow-green watery stools passed on the second or third
day of life. They typically appear when mother's milk starts to come in and increased
amounts of lactose are secreted in the breast milk.

34. Vernix caseosa

44
 - Vernix caseosa is a white, creamy, naturally occurring biofilm covering the skin of the
fetus during the last trimester of pregnancy. Vernix coating on the neonatal skin protects
the newborn skin and facilitates extra-uterine adaptation of skin in the first postnatal
week if not washed away after birth.

35. Wharton’s jelly

- Wharton's Jelly is a gelatinous substance. Its main function is to insulate and protect
the umbilical cord in the womb. It is a primordial mucous connective tissue of the
umbilical cord present between the amniotic epithelium and the umbilical vessels

CLO#12: Utilize the different tools in assessing the newborn.

Assessment tools for Newborn
● Physical Assessment - All parents are offered a thorough physical examination
for their baby within 72 hours of giving birth (NHS, 2021).

- The examination includes screening tests to find out if

your baby has any problems with their eyes, heart, hips
and, in boys, testicles (testes).

How is the newborn physical examination done?

The healthcare professional will give your baby a thorough

physical examination.

45
They'll also ask you questions about how your baby is
feeding, how alert they are, and about their general
wellbeing.

Your baby will need to be undressed for part of the

examination.

During the examination, the healthcare professional will also:

● look into your baby's eyes with a special torch to check

how their eyes look and move
● listen to your baby's heart to check their heart sounds
● examine their hips to check the joints
● examine baby boys to see if their testicles have descended
into the scrotum

What does the newborn physical examination check for?

The examination includes an overall physical check, plus 4

different screening tests.

1. Eyes
The health professional will check the appearance and
movement of your baby's eyes.

They're looking for cataracts, which is a clouding of the

transparent lens inside the eye, and other conditions.

About 2 or 3 in 10,000 babies are born with cataracts in one

or both eyes that need treatment.

But the examination cannot tell you how well your baby can
see.

2. Heart
The healthcare professional will check your baby's heart. This
is done by observing your baby, feeling your baby's pulses,
and listening to their heart with a stethoscope.

Sometimes heart murmurs are picked up. A heart murmur is

46
 where the heartbeat has an extra or unusual sound caused by
a disturbed blood flow through the heart.

Heart murmurs are common in babies. The heart is normal in

almost all cases where a murmur is heard.

But about 8 in 1,000 babies have congenital heart disease

that needs treatment.

3. Hips
Some newborns have hip joints that are not formed properly.
This is known as developmental dysplasia of the hip (DDH).

Left untreated, DDH can cause a limp or joint problems.

About 1 or 2 in 1,000 babies have hip problems that need to

be treated.

4. Testicles
Baby boys are checked to make sure their testicles are in the
right place.

During pregnancy, the testicles form inside the baby's body.

They may not drop down into the scrotum until a few months
after birth.

Around 2 to 6 in 100 baby boys have testicles that descend

partially or not at all.

This needs to be treated to prevent possible problems later in

life, such as reduced fertility.
● Brazelton’s Assessment - The Neonatal Behavioral Assessment Scale (NBAS) is an
instrument designed to assess the neurological and
behavioral functioning of newborn and very young infants.
It assesses the infants’ ability to tune out stimuli, to
respond to visual and auditory stimuli, soothability, motor
functioning and reflexes (Aydlett, 2021).

- Recently, Als et al. developed clinical cluster scoring which

47
 may be of value in organizing use of the exam in nursing
practice. The four clinical clusters of behaviors are defined
as: Dimension I—Interactive Processes; Dimension
II—Motoric Processes; Dimension III—Organizational
Processes: State Control; and Dimension IV—
Organizational Processes: Physical Response to Stress
(Brazelton, 2011).
Clinical Cluster Performance

● Dimension I
○ Interactive Processes examines alertness, orientation,
and responsiveness to visual and auditory interaction
and consola-bility with intervention. An exceptionally
good performance is one in which an infant alerts well
and can be sustained in the alert state for most of a
30-minute exam. The infant’s eyes focus on bright
objects or faces and his/her head turns readily to follow
the object. Also, the infant’s head turns readily to locate
auditory stimuli directed toward him/her. Recognition of
the examiner’s early consoling interventions are made,
and the infant quiets in response to interventions less
active than being picked up and held. A poor
performance is one in which an infant cannot be
brought to the alert state for more than a brief time.
Consequently, the ability to orient to a face and/ or
object is low and the head does not turn to follow or
locate such stimuli. The infant does not assimilate the
examiner’s attempts to console, and hence, does not
console well, unless actively picked up and rocked.
Infant responses rated between these extremes of good
and poor are considered average in interactive
processes.

● Dimension II
○ Motoric Processes examines motor tone and activity. An
exceptionally good performance is one in which an
infant has good tone when handled but relaxes
between handlings. There are normal reflexes, and the
activity level is moderate. The infant shows coordinated
motor activity by smooth movements, some head

48
 control, and hand-to-mouth or other directed
movements. A poor performance is one in which the
infant is markedly hypertonic or hypotonic and shows
immature movements such as jerkiness, poor head
control attempts, low activity or constant unconsolable
activity, and several hyper- or hypotonic reflexes. An
average performance ranks between these extremes.

● Dimension III
○ Organizational Process: State Control examines the
infant’s ability to achieve and maintain an alert state,
control irritability, and habituation to (shutting out of)
disturbing stimuli. An exceptionally good performance is
one in which the infant can achieve a good alerting and
can, when drowsy, shut down whole body responses to
repeated stimuli. Also, the infant easily returns to
alertness after crying and has capabilities in quieting
self, few state swings, and low irritability. A poor
performance in this dimension may be of two types:
high irritability or excessively depressed. High irritability
may be demonstrated by a large number of state
swings, early sustained irritability, and the inability to
shut out stimuli or quiet self. Also, a very flat,
depressed infant would score poorly in this cluster if
he/she remained drowsy when encouraged to awaken
and showed few irritable responses to unpleasant
stimuli. The average response would lie between these
good and poor extremes.

● Dimension IV
○ Organizational Processes: Physical Response to Stress is
concerned with physical symptoms associated with
handling and dressing. A poor performance is one in
which the infant shows profound skin color change and
slow recovery of good color, and is frequently startled or
tremulous even when alert. Lesser reactions are
considered average.
● Silverman-Anderson The Silverman-Andersen Retraction Score (SAs) is used to
Index assess severity of respiratory distress in newborn and preterm

49
 infants without respiratory support. It consists of five items:
(1) chest retraction as compared with abdominal retraction
during inhalation; (2) retraction of the lower intercostal
muscles; (3) xiphoid retraction; (4) flaring of the nares with
inhalation; and (5) grunting on exhalation. Each of the five
factors is graded 0, 1, or 2. The sum of these factors yields
the score. Adequate ventilation is indicated by a 0, severe
respiratory distress is indicated by a score of 10.

Score 10 = Severe respiratory distress

Score ≥ 7 = Impending respiratory failure
Score 0 = No respiratory distress
● Ballard’s Assessment for An examination called the Dubowitz/Ballard Examination for
Gestational Age Gestational Age is often used. A baby's gestational age often
can be closely estimated using this examination. The
Dubowitz/Ballard Examination evaluates a baby's appearance,
skin texture, motor function, and reflexes.

How is physical maturity assessed?

The physical assessment part of the Dubowitz/Ballard
Examination examines physical characteristics that look
different at various stages of a baby's gestational maturity.
Babies who are physically mature usually have higher scores
than premature babies.

Points are given for each area of assessment, with a low of

minus one or minus two for extreme immaturity to as high as
plus 4 or plus 5 for postmaturity. Areas of assessment include
the following:

● Skin textures (for example, sticky, smooth, peeling)

● Lanugo. This is the soft downy hair on a baby's body. It
is absent in immature babies, then appears with
maturity, and then disappears again with postmaturity.
● Plantar creases. These creases on the soles of the feet
range from absent to covering the entire foot,
depending on the maturity.
● Breast. The thickness and size of breast tissue and
areola (the darkened ring around each nipple) are

50
 assessed.
● Eyes and ears. Whether or not eyes are fused or open,
and the amount of cartilage and stiffness of the ear
tissue are noted.
● Genitals, male. The presence of testes and appearance
of scrotum, from smooth to wrinkled, are assessed.
● Genitals, female. The appearance and size of the clitoris
and the labia are assessed.

How is neuromuscular maturity assessed?

Six evaluations of the baby's neuromuscular system are
performed. These include:

● Posture. How the baby holds his or her arms and legs.
● Square window. How far the baby's hands can be flexed
toward the wrist.
● Arm recoil. How far the baby's arms "spring back" to a
flexed position.
● Popliteal angle. How far the baby's knees extend.
● Scarf sign. How far the elbows can be moved across the
baby's chest.
● Heel to ear. How close the baby's feet can be moved to
the ears.

A score is assigned to each assessment area. Typically, the

more neurologically mature the baby, the higher the score.

When the physical assessment score and the neuromuscular

score are added together, the gestational age can be
estimated. Scores range from very low for immature babies
(less than 26 to 28 weeks) to very high scores for mature and
postmature babies. However, the score might not be accurate
in very low birth weight preterm infants (birth weight less
than 1500 grams).

CLO#13: Discuss the importance of assessing the newborn.

51
● To assess newborn’s adaptation to extrauterine life.
● To help find for possible birth defects, complications or problems.
● To establish baseline anthropometric measurements of the child.
● To assess newborn’s growth and need for fluids and nutrition.
● To assess newborn’s overall well-being.
● To determine newborn’s normal function of body systems.
● To help with newborn’s neuromuscular and physical maturity estimates.

CLO#14: Discuss the major points of Newborn Screening Act of

2004.

● The Newborn Screening Act of 2004 seeks to further succeed in reducing morbidity and
mortality associated with certain congenital disorders as it allows timely medical
intervention for diagnosed patients.
● To detect a genetic and metabolic disorder in newborns that may lead to mental
retardation and even death if left untreated.
● According to The LawPhil Project(n.d.), The DOH and the Philippine Health Insurance
Corporation (PHIC) shall require health institutions to provide newborn screening services
as a condition for licensure or accreditation.
● All infants born in the country shall be tested for the hereditary disorders such as, but not
limited to, the following:
○ Congenital Hypothyroidism;
○ Galactosemia;
○ Phenylketonuria;
○ Cystic Fibrosis;
○ Congenital Adrenal Hyperplasia;
○ Maple Syrup Urine Disease;
○ Homocystinuria;
○ Biotinidase Deficiency;
○ Medium Chain Acyl CoA Dehydrogenase Deficiency;
○ HIV Seropositivity;
○ Sickle Cell Disease; and
○ Other Blood abnormalities as determined by the Department.

CLO#15: Explain the principle involved in assessment of the

newborn.
● Anatomy and Physiology

It is vital to know the physiological landmarks of the baby to confirm

normality in the different systems. Possible abnormalities and complications may

52
 also be detected in early stages. Furthermore, we are able to understand not only
the theoretical concepts, but the operating fundamental mechanisms of the baby
as well. Pregnant women undergo important physiological alterations and
adaptations that are needed to survive the demands of childbirth. With that, it is
also to ensure safety before, during, and after the delivery by knowing the basic
knowledge of their Anatomy and Physiology.

● Microbiology

For the reason that babies are known to be under the immunocompromised
group, clients with weak immunity, healthcare professionals are required to
observe proper sanitation procedures. Complying with the standard sterile
techniques, it can prevent Healthcare Associated Infections from the mother and
the baby before, during, and after the delivery. The concept of handwashing is
also the most important and fundamental practice for preventing and controlling
illnesses. Healthcare professionals with contaminated hands are one of the causes
of cross-infection, therefore, we must wash our hands thoroughly especially when
assessing the newborn.

● Safety and Security

In assessing the newborn, healthcare professionals are required to carefully

inspect the materials and equipments used for the assessment. Following the
different safety measures, it prevents any harm to the baby in cases where any
mishaps might happen. It is also to put the parents’ mind at ease that their baby is
in good hands. For childbirth, it is most important to provide comfort and privacy
to the client. It can help manage their pain during labor as the mother focuses on
having a normal delivery and nothing else. Thus, it is the healthcare professionals’
job to make the client’s experience of their delivery a positive one.

● Physics

Thermoregulation is advised when caring for a newborn as they are more

sensitive to changes in temperature due to their small and fragile bodies. In the
first few minutes after the delivery, it is important to balance the heat production
and heat loss to avoid the baby from having hypothermia. This is where they place
the newborn in a closed incubator that is set at 37 degrees celsius or establish the
skin-to-skin care. By keeping the newborns at optimal temperature, they are able
to conserve energy and build up reserves.

● Time and Energy

Checking the functionality of the equipments used for assessment is most

vital. This prevents the process from having any delays and perfect time
management is observed. It also ensures the accuracy of the data collected so
that the healthcare professional can track the progress and status of the newborn.

53
 Considering time can also help the healthcare professionals in knowing when to do
a certain test for the newborn, example is the APGAR test, which is taken at 1
minute and 5 minutes after birth.

● Body Mechanics

Observing proper body mechanics can help avoid fatigue when caring for a
newborn or assisting in childbirth. The entire process requires carrying different
supplies and equipment while carrying out other procedures for how many hours
in a day. When not observed, this puts the healthcare professionals at risk for back
injuries or physical strain. Such measures are used to not only protect the
healthcare professional, but the patients as well. It gives the healthcare
professionals more energy to attend to the needs of their patients, especially in
monitoring the newborn’s condition 24/7 at the nursery room.

● Mathematics

Measurements are taken after the delivery of a newborn to keep track of

their development and growth. The infant's weight, length, belly circumference,
and head circumference would all be measured. The unit of measurement may
differ depending on the device being used, so it's critical for the nurse to
understand measurement conversion techniques to obtain accurate and
trustworthy data. Above all, anthropometric measurements are an important
clinical tool for diagnosis of abnormally small or large newborns.

● Psychology

In childbirth, it is necessary for the mother to comprehend what will happen

to them before, during, and after the delivery. The patient's uneasiness during
childbirth will be lessened by building rapport and projecting a kind, safe, and
welcome aura. For a mother to experience a normal birth process, they must have
a relaxing and natural mindset as the process requires an intense physical change
and emotional upheaval.

CLO# 16: List guidelines in assessing the newborn.

Within 24 hours of birth, a newborn should undergo a thorough evaluation to detect any abnormalities
that might change the path of a typical newborn or to discover any medical conditions that need to be
treated (such as malformations, birth traumas, jaundice, or cardiopulmonary diseases). This evaluation
comprises a thorough physical examination as well as a study of the mother's, family's, and pregnancy
history. Before leaving the hospital, another examination should be done within 24 hours, depending on
the length of stay. Assessments after birth may include:

54
 Apgar Scoring The Apgar Score aids in identifying respiratory problems and other
health problems. The new born’s heart rate, breathing rate, muscle
tone, reflexes, color, etc. are checked 1 minute and 5 minutes after
birth.

Babies are weighed daily at the nursery to monitor their growth and
Birth Weight their need for fluids and nutrition. A newborn often loses 5-7% of
their birth weight. Babies usually return to this weight within the
first two weeks of life. Premature and sick babies may not gain
weight at the same rate.

Measurements The newborn’s head circumference, abdominal circumference and

length are measured. Vital signs such as temperature, pulse and
breathing rate are monitored as well.

Physical Exam A complete physical examination is an integral part of newborn care.

Health care providers carefully examine the health and normal
functioning of each body system. Health care providers also monitor
for signs of illness or birth defects.

Gestational This assessment utilized Dubowitz/Ballard Examination and aids in

Assessment finding the best care for the newborn if the pregnancy date is
unknown. This assessment allows accurately estimating the baby's
gestational age. The baby's skin, other physical features, movements
and reflexes are examined. The physical maturity portion of the exam
is administered during her first two hours of labor. The motor and
reflex portion of the test is performed within 24 hours after birth.

Physical maturity The physical maturity portion of the Dubowitz/Ballard test addresses
physical characteristics that appear different at different stages of a
newborn's gestation.

CLO# 17: Enumerate and discuss nursing responsibilities before,

during and after assessment of the newborn.

BEFORE
● Verifying identification of the newborn
● Reviewing the birthing parent’s pregnancy history
● Explaining newborn assessment to parents

DURING
● Utilizing a systematic approach in examining the newborn
● Conserving newborn warmth and energy
● Conducting the Apgar test
● Conducting a complete physical exam
● Using clinical judgement in determining the need and the urgency of follow-up for all
abnormal findings
● Providing immediate pre-referral treatment if needed

55
ATER
● Informing the physician for any abnormalities
● Documenting relevant information into the newborn's personal health record
● Documenting completion of the assessment in the newborn’s medical record, along with
associated discussions, conclusions and follow-up requirements
● Discussing findings in detail and take the time necessary to discuss the results of the
examination with the newborn’s family
● Ensuring that parents make arrangement for continued health supervision for their
newborn
● Discussing relevant parenting and health education topics with parents

CLO# 18: Recognize the different materials and supplies used in

assessing the newborn and its uses.

1. Measuring Tape

- Measures newborn’s body parts.

2. Stethoscope

- Listens to sounds made by the heart, lungs or intestines, as well as blood flow in
arteries and veins.

3. Thermometer

56
 - Measures temperature.

4. Baby weighing scale

- Measures baby’s weight.

5. Ophthalmoscope

- Detects and evaluates symptoms of retinal detachment or eye diseases

57
6. Otoscope

- Visualizes and examines the condition of the ear canal and eardrum.

CLO# 19: Document client responses and outcomes after

assessment of newborn.

19.1 Maternal History

- History of Past Illnesses

- Questions about a woman’s past medical history are of importance because
a past condition can become active during or immediately following
pregnancy. Representative diseases that pose potential difficulty during
pregnancy include kidney, heart diseases, hypertension, STDs, diabetes,
thyroid disease, seizures, gallbladder disease, UTI, varicosities,
phenylketonuria, tuberculosis, and asthma.
- Childhood diseases are also a cause for concern, such as chickenpox
(varicella), mumps (epidemic parotitis), measles (rubeola), German Measles,
and if the mother has had immunizations against these illnesses.
- From the information gathered, a Nurse can estimate the degree and
amount of antibody protection a woman has against these diseases if she
will be exposed to these diseases during her pregnancy.
- It is also important to ask about allergies, or if they are sensitive to drugs.
This is important for prenatal treatment of any potential infections that may
occur during her pregnancy.

- History of Family Illness

- Being able to identify the illness that frequently occurs in a woman’s
relatives will give insight and potentially identify problems a woman or her
infant could experience during pregnancy or after birth.
- Specifically, ask about cardiovascular and renal issues/diseases, and known
genetically inherited diseases.

- Day History/Social Profile

58
 - Current information about a woman’s nutrition, recreation, and interpersonal
interactions can also be asked by having the woman describe what her
typical day is like.
- Menstrual History
- A woman’s past experience with her reproductive system may have some
influence on how well she accepts the pregnancy, as well as whether or not
she will develop a complication during the event. Her age of menarche,
interval, duration, amount of menstrual flow, and discomfort she feels
during her menstrual period.
- This is important because some women have severe dysmenorrhea, which
can cause the woman to feel less confident and anxious about giving birth.
Counseling is a good intervention for the woman in this case, and a nurse
must recommend it to the client if this is the case.

- Past Surgeries
- Any past surgery on the reproductive tract is important to document
because it can influence a woman’s ability to conceive and give birth.

- Sexual History
- Include the number of sexual partners and use of safe sex practices to be
able to determine if the woman is at risk of a sexually transmitted disease.

19.2 Vital Statistics and Head-to-Toe Assessment

- This includes the baby’s weight, length, and head and chest circumference.
- Weight
- If newborns are breathing well, they are then weighed nude and
without a blanket soon after birth in the birthing room. This is
important to note because it helps to determine the maturity of the
newborn, and as well as establish a baseline against which all other
weights can be compared.
- After the initial weight documentation, the infant is then weighed
nude once a day at the same time the initial weighing took place.
- The weight of newborns will vary depending on the racial, nutritional,
intrauterine, and genetic factors that were present during the
pregnancy.
- The weight in relation to the gestational age should be plotted on a
standard neonatal graph. This information also separates those who
are small for their gestational age from preterm infants.

- Length
- A newborn’s length at birth in relation to weight is a second
important determinant used to confirm that a newborn is healthy.
- The average birth length of a mature female newborn is 49cm.
- For mature male newborns, the average birth length is 50cm.
- The lower limit of expected birth length is arbitrarily set at
46cm

59
 - Although rare, babies can be as great as 57.5cm.

- Head Circumference
- This is measured with a tape measure drawn across the center of the
forehead and then around the most prominent portion of the
posterior head (the occiput).
- In a mature newborn, the head circumference is usually 34 to
35cm
- A mature newborn with a head circumference greater than
37cm or less than 33cm should be carefully assessed for
neurologic involvement, but some newborns are still well and
have these measurements still.

- Chest Circumference
- This is measured at the level of the nipples. If a large amount of
breast tissue is present, this measurement will not be accurate until
the edeme has subsided. In a newborn, it is about 2cm less than the
head circumference.

19.3 Vital Signs

- Temperature
- The temperature of newborns is about 37.2C at birth. This is because they
have been confined in their mother’s warm uterus. Temperature will
immediately fall below normal because of heat loss, the temperature of
birthing rooms (approximately 21 to 22C).
- The majority of heat loss occurs because of four separate mechanisms:
convection, radiation, conduction, and evaporation.
- Convection, flow of heat from the newborn’s body surface to cooler
surrounding air. Eliminating drafts is an important way to reduce
convection heat loss.
- Conduction, transfer of body heat to a cooler solid object in contact
with a baby. Covering surfaces with a warmed blanket is important to
help minimize conduction heat loss.
- Radiation, transfer of body heat to a cooler solid object not in
contact with a baby. Moving an infant as far from the cold surface as
possible helps reduce this type of heat loss.
- Evaporation, loss of heat through conversion of a liquid to a vapor.
Because newborns are wet when born, which makes them lose heat
as the amniotic fluid on their skin evaporates. Lay a newborn on the
mothers abdomen immediately after birth and cover with a warm
blanket for skin-to-skin contact.
- Pulse
- The heart rate of a fetus in utero averages 110 to 160 bpm. Immediately
after birth, the newborn struggles to initiate respirations. This causes the

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 heart rate to go up to as fast as 180 bpm. Within 1 hour of birth, as the
newborn settles to sleep, the heart will stabilize to an average of 120 to 140
bpm.
- The heart rate of a newborn will often remain irregular because of
immaturity of the cardiac regulatory center in the medulla. When the baby
cries, it may rise to 180 bpm again.
- In sleeping, the heart rate may decrease to from 90 to 100 bpm.

- Respiration
- During the first few minutes of the newborn’s life, it may be as high as 90
breaths per minute. But as the newborn settles, the respiratory rate
decreases to an average of 30 to 60 breaths per minute.
- Like heart rate for the newborn, respiratory rate can be irregular as well.

- Blood Pressure
- The blood pressure of a newborn is 80/46 mmHg at birth. By the 10th day,
this increases to 100/50 and remains at that level for the infant year.
- Because of the small size of the infant's arm, it is not regularly checked.
- Blood pressure does tend to increase during crying, so a Doppler method
may be used to achieve better results if a nurse does decide to take the
baby’s blood pressure.
- Hemodynamic monitoring is used when continuous assessment is required.

19.4 Brazleton’s Assessment

- It is best described as a neurobehavioral assessment scale, designed to describe

the newborn’s responses to his/her new extrauterine environment and to

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 document the contribution of the newborn infant to the development of the
emerging parent-child relations

- The Brazelton Neonatal Behavioral Assessment is a rating scale of six different

categories of behavior: habituation, orientation, motor maturity, variation,
self-quieting ability, and social behavior

- A total of 20 to 30 minutes is needed to complete this evaluation, and requires

training to ensure the results are consistent. The infant is scored on best
performance rather than average performance for this objective.

19.5 Silverman-Andersen Index

- This is a standard method in which it can be used to estimate the degrees of

respiratory distress in newborns. The newborn is observed, and scored on each
criteria; Chest Movement, Intercostal Retraction, Xiphoid Retraction, Nares Dilation,
Expiratory Grunt.

- Total Score:
- 0 indicates no respiratory distress
- 1-3 indicates mild stress
- 4-6 indicates moderate distress
- 7-10 indicates severe distress

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19.6 Ballard’s Assessment

- This test is performed if the mother did not have prenatal care. An extensive
criteria will be used to assess the gestational age of the newborn.

- Interpretation:
- Using the standard method of rate maturity, this helps detect infants who
were thought to be term, but instead are actually preterm because of a
miscalculated due date.

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 CLO# 20: Demonstrate beginning skills integrating the CDUCN
Core Values in assessing the newborn

20.1 Head to Toe Assessment/Vital Statistics

Weight In measuring the baby’s weight right after

birth, the baby must be nude and without a
blanket. Other measurements such as body
length, head, chest, and abdominal
circumferences should be done later because
this exposes the infant to unnecessary
chilling.

Length A tape measure is used during this

assessment, and is also considered a second
important determinant to confirm if a
newborn is healthy or not.

Head Circumference The head circumference is measured with a

tape measure drawn across the center of the
forehead, and then around the most
prominent portion of the posterior head.

Chest Circumference With a tape measure, measure at the level of

the nipples. However, if a large amount of
breast tissue is present, the result will be not
accurate until the edema has subsided.

20.2 Brazleton’s Assessment

- Firstly, the examiner briefly shines a light in a sleeping baby’s eyes. A common
outcome would be that the child blinks and squirms in irritation. This process is
then repeated several times, which will then result in the infant tuning out the
stimulation and remain asleep. If a baby is seen to have trouble blocking out that
stimulation, the parents will know that support for their child is needed, such as
keeping the baby from bright lights or staying quiet.

- When an infant’s autonomic, motor, and state systems are in equilibrium, the infant
is ready to interact socially. In this portion of the assessment, the examiner will
present the baby with a red ball, a face, and a voice and see how it affects the
child.

- Another part of the exam is finding out the infant’s ability to self-console when
they are upset. The result of this part of the assessment can be used to identify
the baby’s specific physical needs and behavioral styles. Does the baby like to be
handled? Is the baby receptive to social interaction?

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20.3 Silverman-Andersen Index

- In performing the Silverman-Andersen Scoring, the nurse must be observant of the

respiratory functions of the preterm infant.

- As shown in this picture, the scoring is dependent on the nurse's observation and
understanding of the respiratory functions.
- A nurse must note their findings, and refer to this scoring reference to get the total
interpretation result.

20.4 Ballard’s Assessment for Gestational Age

- There are 2 parts in Ballard's Assessment for Gestational Age; the Physical Maturity
Assessment and Neuromuscular Maturity Assessment. Both are completed within
24 hours after delivery.

- Physical Maturity
- This part of the examination examines physical characteristics that
look different at various stages of a baby’s gestational maturity.
- Babies that are physically mature have higher scores than premature
babies.
- Areas of assessment include:
- Skin textures (if it is sticky, smooth, peeling)
- Lanugo (If the soft downy hair on a baby’s body. In immature
babies, this is absent. And then appears as the baby matures,
but then disappears again with postmaturity.)

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 - Plantar creases (creases on the soles of the feet may be
absent or may be covering the entire foot, depending on the
maturity of the baby.)
- Breast (assesses the thickness and size of breast tissue and
areola.)
- Eyes and ears (whether both are fused or open, and to
identify the amount of cartilage and stiffness of the ear
tissue.)
- Genitals, male (presence of testes and appearance of
scrotum, from smooth to wrinkled.)
- Genitals, female (appearance and size of clitoris and labia
are assessed at this time).

- Neuromuscular Maturity
- Areas of assessment include:
- Posture (how the baby holds his or her arms and legs.)
- Square window (how far the baby’s hands can be flexed
toward the wrist.)
- Arm recoil (how far the baby’s arms spring back to a flexed
position)
- Popliteal angle (how far the baby’s knees extend).
- Scarf sign (how far the elbows can be moved across the
baby’s chest.
- Heel to ear (how far the baby’s feet can be moved to the
ears.

- Typically, the more neurologically mature baby, the higher the score is.

- When both the physical and neurologic maturity assessment results are added, the
gestational age can be estimated.

- For immature babies, less than 26 to 28 weeks. Mature and postmature babies
score higher than this.

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