JMJ Marist Brothers

NOTRE DAME OF MARBEL UNIVERSITY

College of Health Sciences
Nursing Department

Name: ___________________________________________ Group: _____________________

Clinical Instructor: __________________________________ Rating: _____________________

IMMEDIATE NEWBORN CARE

DEFINITION: Early management of the newborn in the delivery room or in the nursery or few
minutes or soon after birth.

PURPOSES:
1. To establish and maintain patent airway for the newborn.
2. To promote measures to prevent hypothermia.
3. To prevent complications.
4. To prevent infection to set in.
5. To record observations of the infant’s condition.

EQUIPMENT:
1. Sterile linen 13. Stamping pad
2. Pair of sterile gloves 14. Agency form for baby’s footprints
3. Rubber bulb suction 15. Name tag
4. Suction machine 16. Basin with lukewarm water
5. Suction catheter (French 5 and 8) 17. Antiseptic or mild soap
6. Rectal thermometer 18. Droplight
7. Alcohol swabs 19. Water soluble lubricant
8. Cord clamp 20. Weighing scale
9. Sterile baby’s layette 21. Tape measure
10. 10% Providone Iodine swabs 22. Sterile gauze
11. 1 cc syringe 23. Baby oil
12. Terramycin eye ointment 24. Baby’s comb

ASSESSMENT RATIONALE

1. Within 60 seconds after the infant’s body is Each sign in the Apgar Scoring system is an
completely born, evaluation should be done index of the infant’s depression or lack of it at
by Apgar Scoring. birth.

2. In the delivery room, perform a general To find out any gross abnormalities or
physical assessment of the infant. evidence of shock or birth trauma.

PLANNING

1. Wear mask, cap and gown. To protect the newborn from microorganisms

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

which may possibly come from the personnel.

2. Wash your hands. Deters the spread of pathogenic

microorganisms.

3. Assemble all necessary equipment. To facilitate easy access, therefore assuring an

organized work.

IMPLEMENTATION

1. Don gloves. To prevent nosocomial infection and maintain

the sterility of the procedure.

2. Care of skin.

A. Using sterile gauze with baby oil, gently To cleanse secretions obtained from passage
wipe the infant’s body starting from the through the birth canal which may become a
face down to the feet. Do not remove all source of infection. Gentle approach will
vernix caseosa. prevent tissue damage. Vernix caseosa may
give protection to infant’s skin by acting as a
lubricant. Besides, vernix caseosa naturally
disappears as it rubs on crib linens or on
infant’s clothing.

B. Hair is gently wiped or combed. Gauze alone cannot remove blood and dirt that
are interspersed with hair strands.

C. If a protocol of the hospital, bath the baby Removes excess blood or vernix caseosa from
with lukewarm water and an antiseptic or the infant’s skin and to enhance the newborn’s
mild soap. smell.

D. Remove gloves and dispose in To prevent spread of microorganisms and

appropriate receptacle. promote cleanliness and orderliness.

3. Care of the cord.

A. Don sterile gloves. To maintain sterility.

B. Holding the clamp, roll the cord up to 4 Following the clean to dirty principle helps
inches above the newborn’s abdomen. prevent recontamination of the cleansed areas.
Disinfect the cord starting from the base Disinfect the chord to prevent infection or
in an upward direction with the use of a complications because the cord is considered
cotton ball soaked in antiseptic solution. an open portal of bacterial entry.
Use one cotton ball per stroke and ensure
that all areas of the cord is disinfected.

C. Clip the cord clamp or tie the cord

securely one inch from the base and cut it
off just above the clamp or tie.

D. Inspect the cord for any undesirable Inspection will help find out cord abnormalities
signs. such as bleeding, foul smelling secretions,
redness and swelling, w/c are signs of possible
infection.

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

E. Apply antiseptic solution 70% Isopropyl To thoroughly disinfect the entire area and
alcohol or Betadine 10%. minimize the possibilities of infection.

F. Dress the cord aseptically by wrapping it That is to maintain the aseptic technique and
with sterile gauze. prevent risking the infant for infection and
complications. The gauze will serve as
protection for the cord from bacterial entry.

G. Wet the cord stump adequately with 70% To ensure that the gauze is totally soaked with
isopropyl alcohol before covering it with antiseptic so that there will be no possibilities
sterile gauze. of infection or complication.

H. Securely keep it in place by wrapping it To prevent the gauze from being dislodged or
with an abdominal binder if it is a hospital removed. The binder will keep the dressing in
protocol. place and will prevent complications, more so
bleeding.

4. Do proper evaluation of the infant using To provide necessary information w/c are
anthropometric measurements (head, chest, indices of abnormalities and to provide
abdominal circumference, length and baseline data for the future progress of the
weight) and record. newborn.

5. Stabilization of body temperature. To check the newborn’s temperature since the

thermostat – his temperature regulating system
is still immature.

A. Insert a rectal thermometer gently and To check anal imperforation to find the need
record the infant’s temperature. Observe for any management.
for unusual findings.

B. Clothe the infant and wrap him properly. To protect the infant from chilling since the
newborn is still sensitive to the sudden change
of temperature outside the uterus.

6. Apply Crede’s prophylaxis on both eyes. To prevent Opthalmia Neonatorum.

7. Prepare Vitamin K 0.5mg (.05ml) for preterm Vitamin K is a blood coagulant therefore it
infants and 1 mg (.1ml) for term infants and protects the newborn from bleeding
inject it intramuscularly into the newborn’s tendencies. (Vit.K is supposed to be
vastus lateralis muscle. synthesized by the normal bacterial flora of the
gastro intestinal tract, but since the newborn’s
GIT is sterile at birth, there is no bacterial flora
to synthesize Vit.K, so it has to be provided by
an external source.)

8. Place the infant’s identification band around To prevent mistakes in the proper identification
the wrist or ankle with the name and sex of of the baby.
the infant, the mother’s name, attending
physician and the date and time delivered.
Get the baby’s footprints and record it in the
chart.

9. If the baby developed serious complications, The nurse should respect the rights of the
the nurse is responsible to coordinate with clients.
the representatives of the affiliated religious

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

groups.

10. If the infant remains in the nursery, place To promote comfort, sleep, and rest on the part
him/her comfortably in the crib or bassinet. of the infant as well as warmth to prevent
hypothermia.

11. If the hospital practices rooming in, bring To promote attachment and maternal-infant
the infant to the mother’s room and give bonding and cuddling, and also to allow other
proper instructions on newborn care. family members to see the newborn. Health
teaching is one of the most basic responsibility
of the nurse to promote understanding and
provide additional knowledge.

12. Do after care. Prevents the spread of pathogenic

microorganisms.
A. Discard all used supplies.
B. Clean thermometer properly. - To prevent nosocomial infections.
- Disinfect the equipment before storing it to
C. Place baby’s social linens in an have it ready for use the next time.
appropriate hamper. - To prevent it from getting contaminated if
D. Wash and dry instruments. mixed with other items.
- To have it ready for future use and prevent
contamination.
EVALUATION

1. Infection is prevented. To ensure that future complications are

prevented and that the infant’s condition is
stable.

2. Respiratory function is well established. To ensure proper airway clearance and

prevent respiratory complications.

3. Skin care has been done properly. To prevent infection or unnecessary skin
rashes or allergies.

4. Cord is taken cared of and assessed for To prevent infection and complications. The
unusual findings. cord is considered an open skin which is at risk
for infection and bacterial growth if not properly
taken cared of.

5. Temperature has been stabilized. To ensure that the possibility of hypothermia is

prevented and to establish warmth for the
infant that is necessary for a newborn.

KEY TERMS AND DEFINITIONS:

Apgar Scoring – the numerical expression of a newborn infant’s well-being and ability to
survive

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care

Vernix Caseosa – a white, cream cheese-like substance that serves as a skin lubricant;
usually noticeable on a newborn’s skin at birth in a term nenonate.

Opthalmia Neonatorum – eye infection at birth or during the first month, most commonly
caused by Neisseria gonorrhoeae or Chlamydia trachomatis
NOTE: can result to corneal ulceration and destruction (severe vision impairment) if left
untreated.

Prepared by: Hannah Sherryl R. Lagunoy, BSN-2B | Newborn Care