Einc Pes

COLLEGE OF NURSING
Visca, Baybay City, Leyte, Philippine

Telephone: (053) 565-0600, local 1012
Email: [email protected]
Website: www.vsu.edu.ph
Performance Evaluation Sheet

Essential Intrapartum and Newborn Care
Name: ____________________________ Year & Sec:_____ Date Performed:______________

Scale for Evaluation:
5- Excellent 1. Performs the procedure correctly.
2. Explain all the rationales correctly.
3. Answer the questions correctly.
4- Very 1. Performs the procedure correctly, with rationales but
Satisfactory failed to answer the questions.
2. Explain all rationales, answer questions correctly but with
minor mistakes.
3. Performs the procedure correctly, answer the questions
correctly but forgot to mention the rationale.
3- Satisfactory 1. Performs the procedure correctly but failed to mention
rationale and answer questions.
2. Perform procedures with minor mistakes, rationales are
incorrect and failed to answer the questions correctly.
3. Explain all rationales, answer questions correctly but
perform the procedure with major mistakes.
2- Needs 1. Performs the procedure incorrectly.

Improvement 2. Forgot the rationales or mentioned incorrectly.
3. Failed to answer the questions.
1-Poor 1. Failed to perform the procedure.
PROCEDURES 5 4 3 2 1 REMARKS
Intrapartal Competencies
Preparation for the delivery of Baby
1. Prepares baby’s layette (bonnet,
mittens, booties, small lines, big linen,
baby’s dress, diaper)
2. Ensures availability of supplies and
medications for use: (tuberculin syringes,
sterile cotton balls (wet and dry), sterile
gauze, 70% alcohol, cord clamps,
thermometer, tape measure, weighing scale
wrist bands, ophthalmic ointment, Vit. K,
vaccines (BCG, Hepa B),
Immediate Newborn Care
1. Dons PPE.
2. Performs handwashing with clean water and
soap.
3. Dons double gloves just before delivery.
4. Covers mother’s abdomen with the first small
linen.
5. Receives newborn and places on top of the
mother’s abdomen.
6. Dries baby thoroughly, by wiping the eyes, face,
head, front and back, arms and legs. Provides
warmth.
7. Does a quick assessment of NB’s breathing
while drying:
During the first 30 seconds
 Do not suction unless the mouth/nose are
blocked with secretions or other material.
 Do not ventilate unless the NB is floppy/limp
and not breathing
If after 30 secs. of thorough drying, NB is not
breathing or gasping, meconium stained:
 Clamp and cut the cord immediately
 Re-position, suction and ventilate
 Prepare for advance resuscitation
If after 30 secs of thorough drying, NB is
breathing or crying
 Do not suction and avoid other manipulations
 Initiate the uninterrupted skin to skin contact
 Initiate “Unang Yakap”
8. Removes wet/used linens and replace it with a
dry one.
9. Spreads vernix caseosa (if present)
10. Positions the NB prone on the mother’s chest or
abdomen.
11. Covers NB’s back with linen/blanket and head
with bonnet.
12. Ensures proper ID of the NB (name tag, name
of mother, date and time of delivery, gender,
name of physician)
13. Monitors cord pulsations.
14. Removes first set of gloves prior to cord
clamping.
15. Performs properly-timed cord clamping with
strict adherence to aseptic technique.
16. Applies the cord clamp about 2cm and 5cm
from the base of the NB abdomen then cut
between clamps using a sterile instrument.
17. Checks cord stump for the completeness of
blood vessels and signs of bleeding.
18. Measures the Anthropometrics of the NB.
19. Checks the temperature.
20. Instills eye ointment starting from the inner to
outer canthus of the eye.
21. Leaves NB on mother’s chest in skin to skin
contact/uninterrupted skin to skin contact with
mother.
22. Does not leave the mother and the NB
unattended. Continues to monitor the NB and
the mother’s mental status.
Within the 90 minutes
23. Observes for feeding cues and provide support
for initiation of breastfeeding. Latch-on the NB
to the mother’s breast.
24. Encourage the mother to nudge the NB. Advise
on correct positioning.
25. Notes for signs of good attachment and
suckling.
Other routine procedures
26. Administers Vitamin K swiftly taking note of the
NB’s weight prior to preparation.
27. Administers BCG immunization.
28. Administers Hepatitis B1 Vaccine.
29. Dons baby’s layette neatly and wrap with
linen/blanket.
30. Room-in with mother.
Counselling
 Breastfeeding (position, attachment, good
suckling, burping, per demand)
 Newborn screening
 Exposure to extreme temperatures
 Monitoring for danger signs
 Bathing and cord care
 Immunizations
 Maternal diet, Breast care and Hygiene
 Clinic visits
 Family planning/Parenting
Documentation:
Attitude Criterion
Dimensions 5 4 3 2 1 Score Remarks
Behavior
Compliance to prescribed
uniform
Completion of the other tasks

(Disposal of used supplies,
keeping the area clean and in
order)
Time efficiency
TOTAL
EQUIVALENT
Knowledge: _________30% Skills: ________50% Attitude: ________20%
Clinical Instructor’s Comments:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Performed by: Evaluated by:
_________________ _________________ _________________

Student Nurse Clinical Instructor Course Spearhead
Name and Signature Name and Signature Name and Signature

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COLLEGE OF NURSING

Visca, Baybay City, Leyte, Philippine

Performance Evaluation Sheet

Name: __________________________ Year & Sec:_ Date Performed:____________

2- Needs 1. Performs the procedure incorrectly.

Completion of the other tasks

Knowledge: _30% Skills: 50% Attitude: 20%

Clinical Instructor’s Comments:

Performed by: Evaluated by:

_________ _ _________

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