LEOPOLD’S MANEUVER 3. Clean and support perineum.

1. Explain procedure. 4. Call out time of birth and sex of

2. Instruct client to empty her the baby.
bladder. 5. Dry the baby for 30 seconds
3. Position client: Supine, knees with the first towel.
slightly flexed with small pillow a. Sequence: Eyes, face, head,
or rolled towel under one side. front and back, arms and
4. Wash hands. legs.
5. Observe women abdomen for b. Then remove wet cloth and
longest diameter and where the place a new one. (You are
fetal movement is apparent. also assessing the baby’s
6. Fundal Grip: Palpate superior breathing at this part).
surface of fundus. 6. Immediate skin-to-skin contact:
7. Umbilical Grip: Palpate sides of a. Position baby in prone over
the uterus while one hand the mother’s chest or
remains stationary on one side abdomen. (Face turned on
while the other palpates the the side to prevent
opposite side. obstruction.)
b. Cover the newborn’s back
Use stethoscope to listen for with a dry blanket.
FHR. c. Put a baby bonnet.
8. Pawlik’s Grip: Grasp the lower 7. Remove the first set of gloves
portion of the abdomen just prior to cord clamping and
above the symphysis pubis cutting.
between thumb and index finger 8. Clamp and cut the cord.
and tries to press the thumb a. Plastic cord clamp 2 cm
and index finger together. above the base.
9. Pelvic Grip: Face the foot of the (Clamp when pulsation has
client. Place finger on both sides stopped.)
of the uterus approximately 2 b. Instrument clamp 3 cm
inches above the inguinal above the plastic cord clamp
ligaments, pressing downward (or 5 cm above the base).
and inward in the direction of c. Cut near plastic clamp.
birth canal. 9. Inject oxytocin via IM into
EINC mother’s deltoid. (10 IU)
1. Layout materials in a linear 10. Deliver placenta (then check
manner. perineum).
Arrangement: Gloves, dry linen, a. Check placenta for
bonnet, oxytocin injection, completeness.
plastic clamp, instrument clamp, 11. Initiate breastfeeding.
scissors, 2 kidney basins. 12. Counsel on proper attachment
In separate sequence after the and positioning.
first breastfeed: Eye ointment, 13. Administer the following after
stethoscope, Vitamin K, Hep B breastfeeding:
and BCG vax. a. Eye ointment (inner canthus
2. Wash hands and wear gloves to outer canthus)
(double gloving).
b. Vit K (O.1 mL, left vastus 9. Close the bag.
lateralis, IM) 10. Proceed with specific nursing
c. Hep B vax (0.5 mL, right care.
vastus lateralis, IM) 11. Clean and alcoholize the things
d. BCG vax (0.05 mL, right after completing nursing care.
deltoid, ID) 12. Perform handwashing again.
14. Anthropometric measurement: 13. Open the bag and put materials
a. Head CC back in.
b. Chest CC 14. Remove apron, folding it away
c. Abdomen from the body, with soiled side
d. Arm folded inwards, and clean side
e. Thigh out, and put it back inside the
f. Length bag.
g. Weight 15. Fold the plastic/linen lining and
BAG TECHNIQUE place it inside bag and close.
1. Place bag on a flat surface lined 16. Make post visit conference.
with paper lining, clean side out 17. Schedule next visit.
(folded part touching the table). 18. Clean and alcoholizes articles
2. Ask for a basin of water if the before putting it inside the bag
faucet is not available then place again.
it outside the work area. 19. Gets the bag from table,
3. Open the bag and take out a. Fold the paper lining (and
linen/plastic lining and spread inserts)
over the work area (clean side b. And places it between the
out). flaps and cover the bag.
4. Take out the towel, soap dish INTRAMUSCULAR INJECTION
and apron and place it on one 1. Perform hand hygiene.
corner of the work area (within 2. Prepare medication for drug
the confines of the linen/plastic withdrawal.
lining). 3. Change needle when feasible.
5. Perform hand washing. 4. Invert syringe and expel excess
a. Wipe with a dry towel. air.
b. Leave the plastic wrappers of 5. Provide client privacy.
the towel in soap dish in the 6. Check client’s identification
bag. band.
6. Wear the apron. 7. Position client in sitting position.
a. Right side out and wrong 8. Explain purpose of medication,
side with crease touching the using language that the client
body. will understand, including
b. Slide the neck into the head relevant information about
strap. effects od medication.
c. Ties strap at the back. 9. Locate exact site for the
7. Take out things needed for a injection.
specific case and place them in 10. Wear clean gloves.
one corner of the plastic area.
11. Cleanse site (circular motion).
8. Place waste bag outside work
area.
12. Hold a swab between the third 14.Stabilize syringe.
and fourth finger of non- 15.Inject medication.
dominant hand. 16.Withdraw needle.
13. Allow skin to dry. 17.Activate needle safety and
14. Remove needle cover and device and apply band-aid if
discard. indicated.
15. Hold syringe between thumb 18. Do not massage area (inform
and forefinger of dominant client as well).
hand. 19. Dispose syringe.
16. Insert needle then hold the 20. Remove gloves.
barrel of the syringe with the 21. Encircle injection site.
non-dominant hand. 22. Document relevant information.
17. Aspirate. NASOGASTRIC FEEDING FOR NEONATE
18. Inject. 1. Explain procedure to client and
19. Wait 10 seconds then withdraw gain informed consent.
needle. 2. Wash hands.
20. Apply gentle pressure with a 3. Put a protective towel or napkin
dry sponge. over neonate’s chest.
21. Discard needle and syringe to 4. Place in feeding position (right
proper receptacle. side lying, with head and chest
22. Remove gloves and perform slightly elevated).
hand hygiene. 5. Aspirate tube before feeding.
23. Document. 6. Attach reservoir to catheter and
24. Assess the effectiveness of the fill it with feeding. Hold infant
drug. when possible.
INTRADERMAL INJECTION 7. Feeding should be slow. Do not
1. Perform hand hygiene apply pressure. Elevate reservoir
2. Prepare medication for drug 6-8 inches above patient’s head.
withdrawal. 8. When feeding is completed, the
3. Explain to the client that the catheter may be irrigated with
medication will produce a small clear water. Before the fluid
wheal or bled. reaches the end of the catheter,
4. Provide privacy. clamp it off and withdraw it
5. Select a site. quickly.
6. Wear gloves. 9. Discard the feeding tube and
7. Cleanse site (circular motion). any leftover solution.
8. Allow are to dry thoroughly. 10. Burp the patient. (Carry over
9. Remove needle cap. shoulder and rub or tap the
10. Expel air or bubbles. back)
11. Grasp syringe with dominant 11. Place the patient on his right
hand, between thumb and side for 1 hour.
forefinger. 12. Observe patient and note for
12. Taut skin. vomiting or abdominal
13. Insert tip of needle (outline of distension.
bevel should be visible under 13. Record procedure.
skin surface).
NEONATAL RESUSCITATION 7. Neonate still has no progress.
1. Prepare are for delivery. a. Hold baby’s chest with two
2. Do handwashing and don hands while placing the
gloves. thumbs on the lower third of
3. Neonate has abnormal breathing the sternum just below the
or poor cry, cyanotic or with low nipple line.
HR (less than 100 bpm) b. Compress chest.
a. Thoroughly dry and keep the c. Provide three chest
baby warm (cover infant in compressions to one breath
blanket). with the help of another
b. Clear the airway (lift and turn attendant. (10 cycles)
neonate on side; Clear d. Listen to heart rate using
mouth first then nose). stethoscope and observe for
c. Stimulate. (Baby, are you chest movements.
okay; Don’t forget to tap e. Continue giving ventilation
sole) breaths for 30 seconds if
4. Neonate is still pale or cyanotic, baby has still irregular
floppy, no breathing and has HR breathing/gasping. (Do again
of <100 bpm. the jaw thrust technique
a. Position the baby’s head in a before continuing ventilation
neutral position. breaths.)
b. Place ambu bag over baby’s 8. If the heart rate is still <60 bpm
mouth and nose using C and then epi is administered along
E finger technique. with continued PPV and chest
c. Provide 5 inflation breaths. compressions.
1-2-3 9. After 10 minutes of continuous
2-2-3 and adequate resuscitative
3-2-3 efforts, discontinuation of efforts
4-2-3 may be justified.
5-2-3 EYE ASSESSMENT
d. Reposition and repeat 1. Evaluate distant visual acuity
maneuver. using Snellen chart.
5. Neonate is still pale or cyanotic, - 20 ft away from Snellen
floppy, with irregular or no chart.
breathing, HR increases but still - One eye at a time.
<100 bpm, with noted chest 2. Evaluate near visual acuity using
movements. hand-held chart.
a. Use jaw thrust technique and - 14 inches away from eyes.
place bag valve mask over 3. Confrontation Test:
baby’s face. a. Peripheral vision.
b. Provide ventilation breaths b. Instruct client to look at
by squeezing the bag about nose.
1-2 seconds for about 30 c. Stretch both hands. (Show
seconds (pump on even fingers)
numbers). d. Count total number of
6. If neonate is now breathing, fingers.
provide post-resuscitation care. 4. Corneal Light Reflex:
a. Shine light over the bridge - In a darkened room, have
of the nose while client client focus on a distant
stares straight ahead. object, shine a light
b. Penlight must be obliquely into the pupil and
approximately 12 inches observe the pupil’s reaction
away from the client’s face. to light. Normally, pupils
5. Cover test: constrict.
a. Use opaque card to cover - Pupil
the aye one at a time. Equal
b. Or ask client to cover one Reactive to
eye on the distant object. Light
c. Remove opaque card and Active
observe the previously EAR ASSESSMENT
covered eye for any 1. Inspect auricle, tragus, and
movement. lobule.
d. Repeat test on opposite eye. 2. Palpate auricle and mastoid
6. Position test: process for tenderness.
a. Instruct client to look and 3. Inspect the external auditory
focus on penlight. canal and tympanic membrane
b. Penlight must be 12 inches using an otoscope.
away from face. 4. Valsalva Maneuver:
c. Move object through 6 - Observe the center of the
cardinal positions. (1, 3, 5, 7, tympanic membrane for a
9, 11) flutter.
7. Inspect eyelids, lashes, eyeball - Pinch nose, close mouth, puff
sockets, bulbar conjunctiva and air.
sclera. 5. Whisper test:
8. Inspect palpebral conjunctiva. - Stand 1-2 feet behind the
- Evert lower eyelid. client.
- Ask client to look up and - Ask the client to place her
assess. finger on her tragus one at a
9. Inspect lacrimal apparatus over time as you whisper a two-
the lacrimal glands and puncta. syllable word behind her.
- Push lateral eyelids upward. 6. Weber test:
- Ask client to look up. - Strike tuning fork and place
10. Palpate lacrimal apparatus and on the center of the head
nasolacrimal duct. and ask whether the client
- Wear gloves prior to hears the sound better in
palpation. one ear or the same in both
11. Shine light to cornea to ears.
determine transparency. 7. Rinne test:
- Oblique direction (from side - Strike then places the tuning
to center). fork on mastoid process.
12. Inspect iris and pupil. - When client no longer feels
- You can shine light. vibration, move it to external
13. Test pupillary reaction to light. ear.
8. Romberg test:
- Ask the client to close feet
together, arms at side, and
close eyes for 20 seconds.
- //Put your arms around the
client (without touching him
or her) to prevent falls//