First procedure is Leopold’s Maneuver, - This maneuver determines whether the

fetal head or breach is in fundus.

Equipment:
 Stand at the foot of the client, facing her
 Mannequin
and place both hands on her abdomen.
 Small pillow/ rolled towel
 Warm water (hand hygiene) - Proper positioning of hands ensures
accurate findings.
 Verify the client.
 Palpate the superior surface of fundus,
- To ensure that you perform the right
procedure to the right client. to determine the consistency, shape, and
 prepare the client and explain the mobility.
procedure. - When palpating a head feels firmer than a
- The explanation reduces anxiety and breech.
enhances cooperation.  Then, perform the second maneuver
which is the umbilical grip.
(Good afternoon, ma’am I’m Alliyah Recio
- So, this maneuver locates the back of the
and I will be your nurse for today, so now I’m
fetus.
going to perform the fundus grip, umbilical
 Face the client and place the palms of
grip, pawlik’s Grip, and Pelvic Grip to
each hand on either side of the
determine the fetal presentation and position
abdomen.
of the fetus.)
- Proper positioning of hands ensures
 Instruct the patient to empty her accurate findings.
bladder.  Palpate the sides of the uterus. Hold the
- Because doing so will promotes comfort. left-hand stationary on the left side of
 Position the woman in supine with knees the uterus while the right hand palpates
slightly flexed, so place small pillow or the opposite side of the uterus from top
rolled towel under one side. to bottom. Then hold the right hand
- Flexing the knees relaxes the abdominal steady and repeat palpation using the
muscles. left hand on the left side.
 Wash your hands using warm water. - This method is successful in determining
- Handwashing prevents the spread of the direction where the fetal back is facing.
possible infection.  Perform the third maneuver. (Pawlik’s
 Observe the woman’s abdomen for Grip)
longest diameter and where fetal - This maneuver determines the part of fetus
movement is apparent. at the inlet and its mobility.
- The longest diameter is the length of the  Gently grasp the lower portion of the
fetus. abdomen just above the symphysis
 Perform the first maneuver which is the pubis between the thumb and index
fundus. finger and try to press the thumb and
 finger together. It also determines any  Measure head circumference from the
movement whether the part is firm or center of the forehead to occipital
soft. prominence.
- If the presenting part moves upward so the - It allows the measurement of the largest
examiner’s hand can be pressed together. diameter of head.
 Next is the fourth maneuver. (Pelvic  Next, measure chest circumference at
Grip) the level of the nipple.
- This maneuver determines fetal attitude - It is done to ensure accurate measurement
and degree of fetal extension into the because it should be 2-3 cm less than the
pelvis. head circumference.
 Stand facing the foot of the client.  And measure the abdominal
 Place fingers on both side of the uterus circumference at the level of the
approximately 2 inches above the umbilicus.
inguinal ligaments, pressing downward - Abdomen enlargement results after feeding
and inward direction of the birth canal, because of lax abdominal muscle.
allow fingers to be carried downward.  Then measure the length from the
- So, the fingers will touch the crown to rump then rump to heel.
hyperextended head. The fetal brow is - Holding the infant firmly ensures safety
easily palpated, if the fetus is on posterior and allows an accurate measurement.
position.  In weighing the baby, place carefully the
 Assist the patient in sitting position. baby on the scale. Hold hand slightly
 Wash hands over the newborn while on scale.
- To deter the spread of microorganisms. - It is done to prevent injury.
 Lastly is document the procedure.  Document the result because it serves as
the legal record of the procedure.
The next procedure is taking anthropometric
- For the measurement of head, we have
measurement.
___, which is the normal measurement is
Equipment: 33-35cm. then for the chest is ___ and its
 Baby measurement is less than 2-3cm in the
 Tape measure
head circumference. For the abdominal is
 Alcohol (hand hygiene)
___, same as the chest. For the length is
 First wash hands before the procedure ___. And lastly the weight is ___.
- To prevent the spread of the
The last procedure is the infant bathing.
microorganisms.
 Place the baby in supine position. Equipment:

- This places the infant in the proper  Baby

position.
 Sterile gloves
 Towel
 Cotton balls  Place the infant on towel and dry the
 Washcloth head using the corners of the towel.
 Soap
 Undress the infant. Wet upper
 Basin
 Alcohol (hand hygiene) extremities, front, back, buttocks, and
legs using washcloth. Apply soap and
 Prepare articles needed.
lather.
- It enhances organization and efficiency in
- It helps prepare the infant for bath.
bathing the infant.
 Pick up the infant and slowly lower him
 Wash hand.
into the bathtub to rinse off.
- To deter the spread of microorganisms.
- The infant should be rinse well to prevent
 Done gloves.
irritation of the skin.
- It protects the nurse from coming in
 Support the baby while lifting him from
contact with body secretions.
the tub, by placing your hand and arm
 Place towel, laid out in a diamond
around the infant, cradling his head and
fashion on table next to basin.
neck in your elbow. Grasp his thigh with
- it is needed for drying the infant.
other hand. Dry infants body gently and
 Remove all clothing except shirt and
thoroughly.
diaper. Wipe the eyes using cotton ball
- The nurse must carefully hold the infant
moistened with water, starting from
because he is unable to support his own
inner to outer canthus. Use a cotton ball
head.
for each eye.
 For female infant – separate labia and
- It helps in reducing the heat loss and soap
with a cotton ball moistened with soap
will irritates the eyes.
and water, cleanse downward one on
 Dip washcloth. Make a mitt and wash
each side. Use a new piece of cotton ball
the face, ears, and neck. Then dry all
on each side.
areas thoroughly.
 For male infant – retract foreskin and
- Bath mitt prevents loose ends.
gently cleanse glands penis with a cotton
 Hold infant on one arm or the Football
ball moistened with soap and water.
hold over the tub and wet hair. Soap
- Genitalia must be properly cleansed to
own hands and lather to hair and scalp
prevent infection.
using gentle circular motion.
 Remove gloves.
- Holding the infant in football manner helps
 Redress infant and hold infant for a
in securing the infant in place.
period of following procedure.
 Splash water against head to rinse off.
 Dispose all the used equipment.
- It removes all the soap that could irritate
the scalp. Applying sterile gloves

Equipment:
 Mask & cap (as needed)  Open package keeping gloves on
 Sterile gloves wrapper’s inside surface.
 Powder
 Alcohol (hand hygiene) - Because the inner surface of glove package
is sterile.
 First, examine glove package to  If gloves are not pre-powdered, take
determine whether it is dry and intact. packet of powder from package and
- To ensure that the pair of gloves is sterile. apply lightly to hands held over
 Inspect condition of hands for presence wastebasket or sink.
of cuts, open lesions, or abrasions. - Powder helps in efficiently donning the
 Prepare equipment and supplies. gloves.
a) Package of sterile gloves in proper  Identify right and left glove. Each glove
glove size. has cuff appropriately 5 cm (2cm) wide.
b) Flat working surface, e.g., table Glove dominant hand first.
above waist level. - Proper identification of gloves prevents
c) Cap and mask (optional)
contamination by improper fit.
- It enhances organization and efficiency in  With thumb and first two fingers of
performing the procedure. non-dominant hand, grasp edge of cuff
 Explain use of sterile gloves to client of globe for dominant hand. Touch
(when appropriate) gloves inside surface only.
- To lessen anxiety. - Inner edge of cuff will lie against skin and
(Good afternoon maam, I’m Alliyah Recio thus is not sterile.
and I will be your nurse for today. I’ve  With gloved dominant hand, slip fingers
been using sterile gloves to reduce underneath second glove’s cuff.
infection during intensive procedure.) - Cuff protects gloved fingers.
 Apply mask and cap as needed.
 Carefully pull second glove over non-
 Perform thorough handwashing.
dominant hand. Do not allow fingers
- To deter the spread of microorganism. and thumb of gloved dominant hand
 Arrange glove package on flat surface. touch any part of exposed nondominant
 Remove outer package wrapper by hand. Keep thumb of dominant hand
carefully peeling apart sides. abducted.
- It prevents the inner glove package form - Contact of hand in a glove with exposed
accidentally opening and touching hand results in contamination.
contaminated objects.  Once the glove is on, interlock fingers.
 Grasp the inner package and lay it on a Cuffs usually fall down after
clean, flat surface above waist level. application. Be sure to touch only sterile
- Sterile object held below waist is sides.
contaminated. - It ensures smooth fit over fingers.
  Take dominant gloved hand and grasp - Sterile materials are used to prevent
palmer surface of another glove. Do not infection.
touch exposed wrist.  Open cord clamp and gauze pad then
- It minimizes contamination of underlying drop it on the sterile package.
skin. - To prevent contamination of sterile
 Lift and pull glove straight back off package
dominant hand, hold inverted glove in  Clamp the cord twice with two Kelly
dominant hand, and discard in forceps, an inch apart, 8- 10 cm from
receptacle. the umbilicus and cut in between.
- Outside of glove does not touch the skin - One Kelly forceps will leave on the
surface. mother’s placenta, while the other is left
 With ungloved non-dominant hand, on the baby’s cord.
slide fingers just under cuff of gloved  Check for 2 arteries and 1 vein.
hand. Grasp undersurface of cuff and - To assess any abnormalities.
pull glove straight off. Discard in  Hold the Kelly forceps and position the
receptacle. cord so that it is perpendicular to the
- Fingers should not touch contaminated infant’s abdomen.
glove surface. - This is done to avoid injury.

The next procedure is cord dressing.  Clean the cord with sterile cotton balls
soaked in Povidone Iodine starting from
Equipment:
the base in a circular motion from inside
 Baby going outside; then from the base
 Cord
towards the Kelly forceps making sure
 Sterile gloves
 Plastic cord clamp that all sides are cleansed.
 Gauze pad - This is done to reduce contamination.
 Sterile package
 Do not milk or strip the cord because
 Cotton balls w/ povidone iodine
 Pick up forceps. this might cause hemolysis of RCB’s.
 Micropore tape  Apply a plastic cord clamp 2 cm from
 Alcohol (hand hygiene)
the umbilicus. Make sure it is securely

 First Perform hand hygiene before the locked. Cut between the cord clamp and

procedure. the Kelly forceps to form a cord stump.

- To deter the spread of microorganism. - This is done to allow room between the

 Prepare all needed materials. abdomen and clamp as the cord dries.

- Caregiver should not leave the infant  Inspect the cord for presence of 2

unattended. arteries and 1 vein; report any

 Open the sterile package. abnormalities noted.

 - The presence of only one artery may  Done gloves.
indicate congenital anomalies or  Prepare cotton balls w/ ointment in a
multisystem abnormalities. separate container.
 Clean the stump with sterile cotton ball - This promotes healing and drying of the
moistened with Povidone-Iodine starting cord.
from the top of the stump to the base of  Fold the diaper down, unwrapped the
the cord, then continue cleansing the cord.
base in a circular manner from inside - This is done to protect the cord from
going outside. getting wet.
- To reduce the contamination,  Get a cotton ball moistened with alcohol
 Wrap the cord stamp with sterile gauze and rip or dab on the cord.
or expose it to air, depending on hospital - This promotes healing and drying of the
policy. cord.
- Sterile gauze will serve as protection for  Clean the base of the cord in a circular
the skin around the cord base. motion from inside going outside.
 Remove gloves. - It is cleaned from inside going outside,
 Dispose the used materials. because the most contaminated part is at
- To prevent the spread of microorganisms. the outside.
 Document the procedure.  Apply prescribed antibiotic ointment.
- Documentation serves as legal record. - To prevent infection
 Wrap the cord with new sterile gauze.
Next is the Care of the umbilical cord.
- Sterile gauze will serve as protection for
Equipment: the skin around the cord base.
 Baby with cord stump  Remove gloves.
 Cotton balls w/ ointment
 Place the diaper in proper position.
 Cotton balls w/ alcohol
 Sterile gloves  Dispose the used equipment.
 Diaper - To prevent the spread of microorganism.
 Gauze
 Record the appearance of the cord.
 Micropore tape
 Alcohol (hand hygiene) - Documentation serves as legal record. It
allows continuity of care to patient for any
 Prepare all needed materials. abnormal result such as drainage and
- This is done to reduce the effort of the redness.
caregiver and not leave the infant
Now we are going to administer Vitamin K.
unattended.
 Perform hand hygiene before the Equipment:
procedure.  Baby
- It removes colonizing microorganism.  Syringe (2 needle)
 Sterile Gloves  Aspirate to check for any backflow of
 Vial with medication blood. If none, give the injection slowly.
 Cotton balls with 70% alcohol
 Alcohol (hand hygiene) - This is done to distribute the medication
 Tape evenly and slowly.
 Dry cotton balls  Removes the needle quickly and applies
pressure over the site with dry cotton
 Prepare all needed materials.
ball. Press to avoid gross bleeding.
- It enhances organization and efficiency in
- Both reduce discomfort.
performing the procedure.
 Removes gloves.
 Draws up the correct amount of
 Dispose the used equipment.
medication into the syringe.
- To deter the spread of microorganism.
- To avoid over dosage of medication.
 Document the procedure.
 Perform hand hygiene before the
procedure. - It allows continuity of care to patient for

- It removes colonizing microorganism. any abnormal results such as hemorrhagic

diseases.
 Done gloves.
- It prevents the spread of microorganism. The next procedure is the Crede’s Prophylaxis.
 Select the site for injection (vastus
Equipment:
lateralis). Evaluate the muscle mass.
 Baby
- The large vastus lateralis is located from  Eye ointment
the sciatic nerve and the femoral artery and  Sterile Gloves
vein.  Cotton balls w/ NSS
 Cotton balls
 Clean the site with cotton balls soaked
 Alcohol (hand hygiene)
in 70% alcohol using circular motion
from inside to outside.  Prepare the equipment.
- Prevents infection. - enhances organization and efficiency in

 Get the syringe then uncap the needle. performing the procedure.
 Compresses/grasps the muscle tissue  Perform hand hygiene before the
between fingers using the non-dominant procedure.
hand. - It prevents the spread of microorganism.
- This prevents sudden movement by the  Done gloves.
infant and possible injury. - It protects the nurse from coming into
 Pierce the skin straight down into the contact with body secretions.
top or the thigh at 90- degree angle.  Clean the eyelids carefully with a sterile
- This places the medication into the muscle cotton ball moistened with sterile NSS
rather than the subcutaneous tissue. from the inner to outer canthus of the
 Support the barrel of the syringe. eye.
 - Going from the inner canthus to the outer  Done gloves.
canthus, debris is kept away from the - It prevents the spread of microorganisms.
lacrimal gland.  Turn on the thermometer.
 Retract the lower eyelid using your  Wipe the thermometer with a dry cotton
thumb. ball from bulb to stem.
- This is done to expose the conjunctiva. - It is clean from least contaminated to most
 Drop generous amount of the prescribed contaminated area to prevent the spread of
antibiotic ointment on the lower microorganisms.
conjunctival sac from inner to outer  Apply a lubricant in the base of the
canthus of the eye. thermometer.
- This is done to allow the ointment to - It allows the thermometer to be inserted
spread across the conjunctiva. without irritation to sphincter.
 Wipe off excess medication with sterile  Spread the buttocks of the baby and
OS. inserts the thermometer at the rectal are
- To prevent imitation of surrounding skin for about 0.5 inch and allow to stay for
 Do the same procedure with the other 2-3 minutes.
eye. - It allows sufficient time for accurate
 Remove gloves. measurement and reduces the risk of
 Dispose the used equipment. injury.
- To deter the spread of microorganisms  Once the soft beep heard, remove the
 Document the procedure. thermometer and wipe from stem to
- Documentation serves as legal record. bulb using dry cotton balls.
 Read the result at the eye level.
The last procedure is Taking Rectal
 Clean the thermometer with cotton ball
Temperature of Newborn.
with alcohol.
Equipment:  Removes gloves.
 Baby  Dispose the used equipment.
 Thermometer for rectal  Wash hands
 Sterile gloves
- it prevents the spread of microorganisms.
 Dry cotton balls
 Cotton balls w/ alcohol  Document the result.
 Lubricant - Documentation serves as legal record. The
 Alcohol (hand hygiene)
newborn rectal temperature is ____.
 First prepare the materials.
- It enhances organization and efficiency in
performing the procedure.
 Wash hands before the procedure.
- It removes colonizing microorganisms.