BACHELOR OF SCIENCE IN NURSING

RLE UNIT SKILLS CHECKLIST WEEK

NCMA 217 NEWBRON CARE LF2F | 03

NEWBORN CARE
PROCEDURE: 4 3 2 1
1. Perform hand hygiene
2. Observe for feeding cues at 20 minutes to 90 minutes, encourage mother for full
breastfeeding, once feeding cues are present.
3. After full breastfeeding is completed, perform newborn eye care. Administer ophthalmic ointment on
baby’s eyes. Gently pull down the lower eyelid and apply the Erythromycin ointment from inner canthus
to outer canthus.
4. Close newborn eyes after application and wipe any excess ointment.
5. Administer Vit. K in left vastus lateralis with this dosage, If the newborn is:
 Premature: 0.05 ml/ IM
 Term: 0.1 ml/ IM
6. Administer Hepa B vaccine in Right Vastus lateralis at 0.5 ml/ IM

7. Perform anthropometric measurements by measuring the following:

 Newborn length – 48 to 54 cm, normal
 Head Circumference – 33 to 35 cm, normal
 Chest & Abdomen Circumference – 31 to 33 cm, normal
 Newborn weight – 2,500 to 4000 gm, normal
8. Administer BCG Vaccine in the upper deltoid at 0.05 ml
9. Assess NB’s vital signs & perform 2nd APGAR scoring
10. Dress baby with comfortable baby’s clothing and wrap around baby’s blanket.
11. Encourage mother for continuous breast feeding.
12. Perform first bath within 6 to 12 hours.
SCORE ( / 56 ) * 100 =

Scale:
4 – Exemplary (Competent and Independent)
3 – Proficient ( Requires minimum guidance)
2 – Satisfactory (Requires frequent guidance)
1 – Developing (Requires close guidance)

Name: Section & Group:

Grade:
Signature over Printed Name of Clinical Instructor Date:

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 BACHELOR OF SCIENCE IN NURSING
PERFORMING LEOPOLD'S MANEUVER
PROCEDURE: 4 3 2 1
1. Explain the procedure.
2. Instruct the client to empty her bladder.
3. Wash hands.
4. Place woman in dorsal recumbent position, supine with knees flexed abdominal muscles.
Place a small pillow under the head for comfort.
5. Drape appropriately.
6. Warm your hands first by rubbing them together before placing over the pregnant woman's
abdomen.
7. Use the palm for palpation and not the fingers
FIRST MANEUVER (Fundal Grip)
8. Face the head part of the client.
9. Using the palm of both hands, palpate for the fetal part lying in the fundus.
SECOND MANEUVER (Umbilical Grip)
10. Put both hands on either side of the abdomen, applying gentle but deep pressure.
11. Hold one side of the abdomen steady, gradually palpate opposite side from top to the
lower segment of the abdomen to feel the fetal outline in a slightly circular motion.
12. Repeat the same procedure on the opposite side. To identify fetal parts correctly.
THIRD MANEUVER (Pawlik's Grip)
13. With the right hand, using thumb and finger, gently grasp the lower abdomen above the
symphysis pubis
14. Press in lightly using thumb and finger and make gentle movements from side to side.
15. Identify correctly the presenting part.
FOURTH MANEUVER (Pelvic Grip)
16. Face the client's foot part, place palm on the sides of the abdomen, just above the
inguinal ligament.
17. Grasp snugly the lower abdomen and with the outstretched thumbs meeting at the
umbilical level.
18. Identify correctly the degree of flexion, position and station of the presenting part
19. Prevent unnecessary exposure of client's body and return to position of comfort.
20. Wash hands, Records the findings correctly and relay findings to the client.
SCORE ( / 80 ) * 100 = .

Name: Section & Group:

Grade:
Signature over Printed Name of Clinical Instructor Date:

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 BACHELOR OF SCIENCE IN NURSING
RLE UNIT SKILLS CHECKLIST WEEK
NCMA 217 ACTUAL DELIVERY & NEWBORN CARE LF2F | 02

PERFORMING ACTUAL DELIVERY & NEWBORN CARE

PROCEDURE: 4 3 2 1
1. Provide warmth: Check the environment (Room temperature @25-28C)
 Eliminate air drafts, turn off the aircon.
2. Perform medical handwashing.
3. Prepare all the necessary materials. Separate clean and sterile materials. Arrange the
instruments in proper order.
4. Assist the client in fowlers/sitting position in delivery table.
5. Provide perineal hygiene.
6. Don sterile gloves (double gloving) then place the sterile towel under the buttocks, followed by
leggings and 1 towel in the abdomen.
7. Observe for signs of crowning, advice patient to bear down and perform proper panting.
8. During delivery of the head, encourage the patient to breathe rapidly with mouth open.
 Primi: the physician will perform episiotomy, hand over the bandage scissors and gauze
 Multi: Perform ritgen's maneuver – place a sterile gauze in the perineum
9. Immediately after birth of the head wipe the mouth and nose.
10. Assess for cord coil to determine if there is loop of cord encircling the neck.
 (+) & LOOSE: Loosened and drawn down over the fetal head.
 (+) AND TIGHT: Clamp and cut the cord before shoulders are delivered.
11. After expulsion of fetal head, the nurse should assist the baby during external rotation.
12. Assist in downward pull to deliver the anterior shoulder and upward pull to deliver the rest of
the body.
13. State the time of delivery and the gender of the baby.
14. Place the newborn in mother's abdomen in prone position, dried the newborn’s back and
start the APGAR Scoring.
15. Perform thorough drying for at least 30 seconds (do not wipe off the vernix caseosa [spread]
then remove the soiled towel).
16. Cover the newborn with another sterile towel and place a bonnet to the head to conserve
heat.
17. Administer oxytocin 10 IU (IM) to mother as ordered 1minute after the baby is born and
second baby is ruled out.
18. Remove the 1st gloves before touching the umbilical cord then place it in the
decontamination solution (normal saline + HCL)
19. Wait until the pulsation stop, then clamp the plastic cord at least 2cm above the umbilical
base and clamp again at 5cm from the base. Cut the cord close to the plastic clamp.

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 PERFORMING DELIVERY ROOM & NEWBORN CARE continuation…
PROCEDURE: 4 3 2 1
20. Place the bandage scissors in the kidney basin with decontamination solution (normal saline
+ HCL)
21. Observe for signs of placental separation.
22. If there is lengthening of the cord, the nurse should perform crede's maneuver (during
strong uterine contraction perform controlled cord traction and counter traction until placenta
is out).
23. Observe and note for the time of placental delivery, inspect for the completeness of placenta
and cotyledons.
24. Place the placenta in the kidney basin.
25. Perform perineal hygiene, if perineal stitching is performed, assist the physician.
26. Place the patient in comfortable position
27. Observe for feeding cues at 20–90 minutes, encourage the mother for full breastfeeding,
once feeding cues are present.
28. After full breastfeeding is completed, the nurse may perform eye care.
29. Administer ophthalmic ointment, gently pull down the lower eyelid and apply the medication
from inner to outer canthus.
30. Close the newborn’s eyes and wipe the excess ointment.
31. Administer Vitamin K in left vastus lateralis, if the newborn is:
 Premature: 0.05ml/IM
 Term: 0.1ml/IM
32. Administer Hepa B vaccine in right vastus lateralis at 0.5ml/IM
33. Administer BCG in the upper deltoid at 0.05ml/ID
34. Measure the NB length (48-54cm), head circumference (33 35cm), chest and abdomen (31-
33cm) Weight (2,500-4000grams/5 8lbs/8oz-13oz.) then place the NB identification tag
35. Assess the VS and perform 2nd APGAR SCORING
36. Postponed bathing at least 6 hrs. the mother is place in the stretcher together with her baby
and move in the recovery room or ward.
37. Encourage for continued breastfeeding
38. Perform after care.
SCORE ( / 152 ) * 100 = .

Scale:
4 – Exemplary (Competent and Independent)
3 – Proficient ( Requires minimum guidance)
2 – Satisfactory (Requires frequent guidance)
1 – Developing (Requires close guidance)

Name: Section & Group:

Grade:
Signature over Printed Name of Clinical Instructor Date:

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