FUNCTIONAL

ASSESSMENT TEST
ASSESSING THE
NEWBORN AND INFANT
ANATOMY AND
PHYSIOLOGY REVIEW
 IMMEDIATE NEWBORN ASSESSMENT
Time Band Nursing Interventions /Assessment
Golden Minute  Dry the baby thoroughly by gently rubbing the body, arms
First 1 min. and legs
 Remove the wet cloth
 Place the baby skin to skin with the mother
 Do not wipe off vernix if present
 Cover the baby with a dry cloth
 Note the time of Birth

1-2 min.  1st APGAR Scoring

1-3 min.  Remove the first set of gloves immediately prior to cord
clamping.
 Do delayed or non-immediate cord clamping .
 Clamp and cut the cord after cord pulsations have stopped
(typically at 1 to 3 minutes)
 Put ties tightly around the cord at 2 cm and 5 cm from the
newborn’s abdomen.
 Cut between ties with sterile instrument.
Time Band Nursing Interventions /Assessment
5 min.  2nd APGAR Scoring
Within 90 min. of  Leave the newborn on mother’s chest in skin-to-skin
Age contact.
 Provide support for initiation of breastfeeding
 Do eye care- Administer erythromycin or tetracycline
ointment or 2.5% povidone-iodine drops to both eyes after
newborn has located breast.

90 min to 6 hours  Essential Newborn Care

 Give Vitamin K prophylaxis
 Inject a single dose of Vitamin K 1 mg IM.
 (If parents decline intramuscular injections, offer oral
vitamin K as a 2nd line).
 Inject hepatitis B vaccine 0.5ml intramuscularly and BCG
0.05 ml intradermally
 Check for birth injuries, malformations or defects
NEWBORN ANTHROPOMETRIC
MEASUREMENTS
• MEASURE HEAD CIRCUMFERENCE (33-35 cm)
CHEST CIRCUMFERENCE
Normal Measurement (30.5-33 CM) 2-3cm < HC
ABDOMINAL CIRCUMFERENCE
Normal Measurement similar to Chest
measurement. Should not be distended
LENGTH
Normal Measurement ; Head to heel (45-55 cm)
Crown to Rump (31-35cm)
WEIGHT
Normal Measurement ; Head to heel (2,500 – 4000
g)