PERFORMANCE CHECKLIST

CHECKLIST NEWBORN CARE COMPETENCY

Name of Student: _____________________________

Year/Clinical Group:
__________________________
School Year: ________________________________
Clinical Instructor: ____________________________
NEWBORN COMPETENCIES WEIGHT SCORE REMARKS
I. SAFE AND QUALITY NURSING CARE
1. Establishes and maintains patent airway.
2. Puts newborn in Trendelenburg position.
3. Suctions mouth and nose of the newborn gently.
4. Dries newborn and wraps warmly.
Places under droplight as needed.
5. Performs and interprets APGAR scoring correctly.
Immediately after delivery
After 5 minutes
6. Ensures proper identification of newborn (name tag:
name of mother, date and time of delivery, gender
and name of attending physician).
7. Performs physical assessment.
8. Takes anthropometric measurements including
weight, height, head, chest,
abdominal circumference.
9. Takes vital signs (temperature per rectum to check
patency)
10. Gives oil/water and soap bath according to
institutional policy.
11. Latches newborn to the mother’s breast
immediately after birth.
12. Applies CREDE’s prophylaxis on the eyes.
13. Performs cord dressing aseptically.
Disinfects area properly according to hospital
policy.
Clamps and cuts cord 1 inch from the abdomen.
Checks for the presence of 2 arteries and 1 vein.
Dresses cord aseptically according to hospital
policy.
14. Administers Vitamin K (1mg/M) into the lateral
anterior thigh or vastus lateralis.
15. Keeps baby wrapped warmly under the floor lamp
or beside mother according to institutional
policy until discharge.
16. Records pertinent observations and nursing care
done.
17. Reports any signs of deviation/abnormality to the
pediatrician.

II. MANAGEMENT OF RESOURCES, ENVIRONMENT AND

EQUIPMENT
1. Prepares instrument and equipment needed.
Suction bulb, cord clamp, gauze, cotton
balls, disinfectant, blanket, droplight,
Vitamin K,
antimicrobial, ophthalmic ointment.
2. Ensures use of sterile equipment during immediate
care of the newborn.
3. Maintain adequacy of supplies as newborn care is
rendered.
4. Maintains orderliness of the working area.
5. Observes precautionary measures related to use of 1
electrical equipment.
6. Ensures a warm and quiet environment. 1
7. Uses supplies diligently. 1
8. Ensures proper disposal of waste. 1
III. HEALTH EDUCATION
1. Provides instruction to the mother on daily cord 2
care and prevention of cord infection.
2. Provides discharge instructions to the mother on 1
when to expect cord to fall off or to report signs of
cord infection.
3. Provides information regarding newborn screening, 2
immunization, feeding, etc.
4. Responds to questions of mother and relatives 1
regarding expectations.
IV. LEGAL RESPONSIBILITY
1. Identifies newborn by comparing ID band with data 2
in the chart.
2. Documents all pertinent data correctly and 1
completely.
3. Reports accurately any deviations/abnormal 1
findings and nursing interventions rendered
4. Ensures that birth certificate and other civil 2
registration forms are accomplished/ filled out
according to institutional policy.
5. Performs foot printing according to hospital policy. 1
V. ETHICO-MORAL RESPONSIBILITY
1. Respects the religious, cultural and ethnic practices
of the family of the newborn.
2. Maintains privacy and confidentiality of findings of
assessments.
VI. PERSONAL AND PROFESSIONAL DEVELOPMENT
1. Updates oneself with the latest trends and 1
developments in newborn care.
2. Projects a professional image of the pediatric nurse. 1
3. Accepts criticisms and recommendations. 1
4. Performs functions according to standards. 1
VII. QUALITY IMPROVEMENT
1. Identifies deviation of practice from the standards. 1
2. Participates in audit practices in the nursery. 1
3. Recommends corrective and preventive measures 1
for the identified deviations
 VIII. RESEARCH
1. Identifies researchable problems related to 1
immediate care of newborn.
2. Initiates a research study on an identified 1
researchable problem.
3. Participates as a member of a research team in the 1
conduction of a research study.
4. Utilizes findings of research studies in the 1
immediate care of the newborn.
IX. RECORDS MANAGEMENT
1. Documents accurately relevant data about the 1
newborn.
2. Maintains an organized system of filling and record 1
keeping.
X. COMMUNICATION
1. Utilizes appropriately all forms of communication; 1
verbal, non-verbal, electronic.
2. Maintains an open line of communication with the 1
mother and other family members.
3. Informs mother of relevant information about the 1
newborn.
4. Listens attentively to queries and request of 1
mothers and family members.
XI. COLLABORATION AND TEAMWORK
1. Functions effectively as a team player in the 1
nursery.
2. Communicates findings of assessment to all 1
concerned.
3. Establishes a collaborative relationship with 1
members of the health team and family of the
newborn.
75

COMPUTATION OF GRADES:

STEP 1: Get the sum of all points for the entire procedure
STEP 2: Use the formula below to get the final grade for the particular competency
Checklist

FORMULA: RAW SCORE/ PERFECT SCORE X 60 + 40 = FINAL GRADE

Evaluated by: Conforme:

____________________________ ___________________________
Signature over printed name Signature over printed name
(CLINICAL INSTRUCTOR) (STUDENT)

Date: ____________________ Date:_______________________

EVALUATION CHECKLIST – EINC PROTOCOL

NAME______________________________________________________________________________
AREA OF ASSIGNMENT_______________________________________________________________
DATE OF EXPOSURE_________________________________________________________________
CLINICAL INSTRUCTOR ____________________________________________________________
Directions: Please rate the student’s level of competency on each expected skill using the scale provided
Direction: Please rate the student’s level of competency on each expected skills using the scale provided.
(please put a on the box).

o 2 - Done Independently (Student demonstrates excellent skills, exhibits competency

independently)
o 1 - Done with Assistance (Student demonstrates fair strength in demonstrating skills with close
supervision)
o 0 - Not Done (Student did not exhibit competency in demonstrating skills. Needs improvement)

In advance, prepare decontamination solution by mixing 1 part 5% chlorine bleach to 9 parts water to make
0.5% chlorine solution. Change chlorine solution at the beginning of each day or whenever solution is very
contaminated or cloudy.
PRIOR TO WOMAN’S TRANSFER TO THE DR 2 1 0 Comments
1. Ensure that the mother is in her position of
choice while in labor.
2. Ask the mother if she wishes to eat/drink or
void.
3. Communicate with the mother – inform her of
the progress of labor, give reassurance and
encouragement.
WOMAN ALREADY IN THE DR
PREPARING FOR DELIVERY
1. Check the temperature in the delivery room area
to be 25-28 degrees Celsius; eliminate air draft.
2. As woman if she is comfortable in the semi-
upright position (the default position of the
delivery table)
3. Ensure the woman’s privacy.
4. Remove all jewelry then wash hands thoroughly
observing the WHO 1-2-3-4-5 procedure
5. Prepare a clear, clean newborn resuscitation
area. Check the equipment if clean, functional
and within easy reach.

6. Arrange materials/supplies in a linear sequence.

 Gloves
 Dry linen
 Bonnet
 Oxytocin injection
 Plastic clamp
 Instrument clamp
 Scissors
 2 kidney basins
Separate sequence, for after the first breastfeed:
 Eye ointment
 Stethoscope to symbolize PE
 Vit K
  Hepatitis B vaccine
 BCG vaccine
 Cotton balls

7. Clean the perineum with antiseptic solution.

8. Wash hands and put on 2 pairs of sterile gloves
aseptically. (if same worker handles perineum
and cord)
AT THE TIME OF DELIVERY
9. Encourage woman to push as desired.
10. Drape the clean, dry linen over the mother’s
abdomen or arms in preparation for drying the
bay.
11. Apply perineal support and do controlled
delivery of the head.
12. Call out time of delivery and sex of the baby.
13. Inform the mother of the outcome.
FIRST 3O SECONDS
14. Thoroughly dry the baby for at least 30 seconds,
starting from the face and head, going down to
the trunk and extremities while performing a
quick check for breathing.
1-3 MINUTES
15. Remove the wet cloth.
16. Place the baby in skin-to-skin contact on the
mother’s abdomen or chest
17. Cover the baby with the dry cloth and the baby’s
head with a bonnet.
18. Exclude a 2nd baby by palpating the abdomen in
preparation for giving oxytocin.
19. Use wet cloth to wipe the soiled gloves.
20. Give IM oxytocin within one minute of baby’s
birth.
21. Dispose of wet cloth properly.

22. Remove first set of gloves and decontaminate

them properly (in 0.5% chlorine solution for at
least 10 mins)
23. Palpate umbilical cord to check for pulsations
24. After pulsation stops, clamp cord using the
plastic clamp or cord tie 2cm from the base.
25. Place the instrument clamp 5cm from the base.
26. Cut near the plastic clamp (not midway).
27. Perform the remaining steps of the AMTSL.
 Wait for strong uterine contractions then
apply controlled cord traction and
counter traction on the uterus,
continuing until placenta is delivered.
 Massage the uterus until it is firm.
28. Inspect the lower vagina and perineum for
lacerations/tears and repair tears/lacerations as
necessary.
 29. Examine the placenta for completeness and
abnormalities.
30. Clean the mother, flush perineum and apply
perineal pad/napkin/cloth.
31. Check the baby’s color and breathing; check
that the mother is comfortable, uterus
contracted.
32. Dispose of the placenta in a leak-proof container
or plastic bag.
33. Decontaminate (soaked in 0.5% chlorine
solution) instruments before cleaning,
decontaminate 2nd pair of gloves before disposal,
stating that decontamination lasts for at least 10
mins.
34. Advice mother to maintain skin-to-skin contact.
Baby should be prone on mother’s chest in
between the breasts with head turned to the side.
35. Observe the newborn. Only when the newborn
shows feeding cues (e.g. opening of mouth,
tonguing, licking, rooting), make verbal
suggestions to the mother to encourage her
newborn to move toward the breast e.g.
nudging.
36. Counsel on positioning and attachment. When
the baby is ready, advise the mother to:
 Make sure the newborn’s neck is not
flexed nor twisted.
 Make sure the newborn is facing the
breast, with the newborn’s nose
opposite her nipple and chin touching
the breast.

 Hold the newborn’s body close to her

body.

 Support the newborn’s whole body, not

just the neck and shoulders.
 Wait until her newborn’s mouth is
opened wide.
 Move her newborn onto her breast,
aiming the infant’s lower lip well below
the nipple.
AFTER THE FIRST FULL FEEDING:
37. Do eye care, inject BCG and hepatitis vaccines
and Vit. K
38. Do physical assessment. Weighing, bathing, eye
care, examinations, injections (hepatitis B,
BCG) should be done after the first full
breastfeed is completed
39. Postpone washing until at least 6 hours.
40. Encourage mother to keep baby always on skin-
to-skin contact.
41. Keep both mother and baby comfortable.
 42. Documentation. Fill up forms completely.

COMPUTATION OF GRADES:

STEP 1: Get the sum of all points for the entire procedure
STEP 2: Use the formula below to get the final grade for the particular competency
Checklist

FORMULA: RAW SCORE/ PERFECT SCORE X 60 + 40 = FINAL GRADE

Evaluated by: Conforme:

____________________________ ___________________________
Signature over printed name Signature over printed name
(CLINICAL INSTRUCTOR) (STUDENT)

Date: ____________________ Date:_______________________

 LEOPOLD’S MANEUVER
Evaluation Tool
Direction: Please rate the student’s level of competency on each expected skills using the scale
provided. Allotted time to finish procedure. ( minutes)

o 2 - Done Independently (Student demonstrates excellent skills, exhibits competency

independently)
o 1 - Done with Assistance (Student demonstrates fair strength in demonstrating skills with close
supervision)
o 0 - Not Done (Student did not exhibit competency in demonstrating skills. Needs improvement)

IMPLEMENTATION
PROCEDURE SCORE
2 1 0
1. Provide privacy Put the client at ease
(Delaune and Ladner,
2006)
2. Prepare the Client Explanation reduces
a. Explain the procedure anxiety and enhances
cooperation.
b. Instruct the client to Doing so promotes
empty her bladder. comfort and allows for
more productive
palpation because fetal
contour will not be
obscured by a distended
bladder.
c. Position the woman Flexing the knees
supine with knees relaxes the abdominal
slightly flexed. Place muscles. Using a pillow
a small pillow or or towel tilts the uterus
rolled towel under off the vena.
one side.

d. Wash your hands with Handwashing prevents

warm water. the spread of possible
infection. Using warm
water aids in client
comfort and prevents
tightening of abdominal
muscles.
e. Observe the woman’s The longest(axis) is the
abdomen for the length of the fetus.The
longest diameter and location of activity most
where fetal movement likely reflects the
is apparent. position of the feet.
3. Perform the first This maneuver
maneuver. determines whether fetal
head or breech is in the
fundus.
a. Stand at the foot of Proper positioning of
the client, facing her, hands ensures accurate
and place both hands findings.
 flat on the abdomen.
b. Palpate the superior When palpating, a head
surface of the fundus. feels more firm than a
Determine breech. A head moves
consistency, shape independently of the
and mobility. body; the breech moves
only in conjunction with
the body.
4. Perform the second 3. This maneuver locates
maneuver. the back of the fetus.

a. Face the client and Proper positioning of

place the palms of ach hands ensures accurate
hand on either side of findings.
the abdomen
b. Palpate the sides of This method is most
the uterus. Hold the successful to determine
left hand stationary on the direction the fetal
the left side of the back is facing. One hand
uterus while the right will feel a smooth, hard,
hand palpates the resistant surface( the
opposite side of the back), while on the
uterus from top opposite side, a number
bottom. Then hold the of angular nodulations
right hand steady, and ( the knees and elbows
repeat palpation using of the fetus) will be felt.
the left hand on the
left side.
5. Perform the third This maneuver
maneuver. determines the part of
the fetus at the inlet and
its mobility.
a. Gently grasp the If the presenting part
lower portion of the moves upward so an
abdomen just above examiner’s hands can be
the symphysis pubis pressed together, the
between the thumb presenting part is not
and index finger and engaged (not firmly
try to press the thumb settled into the pelvis). If
and finger together. the part is firm, it is the
Determine any head; if soft, then it is
movement and the breech.
whether the past is
firm or soft.
6. Perform the fourth This maneuver
maneuver. determines fetal attitude
and degree of fetal
extension into the pelvis;
it’s should be done only
if the fetus is in a
cephalic presentation.
Information about the
infant’s anteroposterior
 position may also be
gained from this final
maneuver.
a. Both sides of the The fingers of one hand
uterus approximately will slide along the
2 inches above the uterine contour and meet
inguinal ligaments, no obstruction,
pressing downward indicating the back of
and inward in the the fetal neck. The other
direction of the birth hand will meet an
canal. Allow the obstruction an inch or so
fingers to be carried above the ligament- this
downward. is the fetal brow. The
position of the fetal
brow should correspond
to the side of the uterus
that contained the
elbows and knees of
the fetus. If the fetus is
in the poor attitude, the
examining fingers will
meet an obstruction on
the same side as well as
the fetal back. That it,
the fingers will touch the
hyper extended head. If
the brow is very easily
palpated (as if it lies just
under the skin), the fetus
is probably in a posterior
position (the occiput is
pointing toward the
woman’s back).
7. Document care rendered
accurately.

COMPUTATION OF GRADES:

STEP 1: Get the sum of all points for the entire procedure
STEP 2: Use the formula below to get the final grade for the particular competency
Checklist

FORMULA: RAW SCORE/ PERFECT SCORE X 60 + 40 = FINAL GRADE

Evaluated by: Conforme:

____________________________ ___________________________
Signature over printed name Signature over printed name
(CLINICAL INSTRUCTOR) (STUDENT)
Date: ____________________ Date:_______________________