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JOSE RIZAL UNIVERSITY

College of Nursing and Health Sciences

Performance Checklist
Immediate Newborn Care

Name of Student: __________________ Date: ___________

Year/Section/Group No.: ___________ Grade: __________

Rate the student’s performance by checking the appropriate box using the following criteria:

5- Excellent Carries out procedure efficiently, systematically and independently

4- Very Satisfactory Carries out procedure efficiently and systematically but requires minimal guidance and
supervision

3- Satisfactory Carries out procedure efficiently and systematically but requires moderate guidance and
supervision

2- Fair Carries out procedure with close guidance and supervision

1- Poor Carries out procedure inefficiently and unsystematic

CRITERIA
A. KNOWLEDGE
1. Assess the infant is condition and wash hands.
2. Gather the equipment:
a. Bath towel
b. Complete set of baby dress and diaper
c. Dry cotton balls
d. Wash cloth
e. Soap and soap dish
f. 2 big basin / baby bath tub
g. Warm water
h. Kidney basin
B. SKILLS
3. Place towel, laid out in diamond fashion on top of the table next to basin/bath tub.
4. Remove all clothing except shirt and diaper.
5. Wipe the eyes using a cotton ball moistened with water starting from the inner to outer
canthus. Use new cotton ball for each eye.
6. Dip wash cloth. Make a mitt and wash the face, ears and neck. Dry all areas
thoroughly.
7. Hold infant on one arm (Football Hold) over the basin/bath tub and wet hair. Soap own
hands and lather to hair and scalp using gentle, circular motion. Splash water against
head to rinse off.
8. Place infant on towel and dry the head using the corners of the towel.
9. Undress the infant. Wet upper extremities, front, back, buttocks and legs using wash
cloth. Apply soap and lather.
10. Pick up infant and slowly lower him into the basin/ bath tub to rinse off.
11. Support the infant while lifting him from the tub/basin by placing your hand and arm
around the infant. Cradling his head and neck in your elbow.
12. Grasp his thigh with other hand. Dry infant’s body gently but thoroughly.
13. A. For Female:
1. Separate labia, and with cotton ball moistened with soap and water
cleansed downward one of each side.
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2. Use new piece of cotton ball on each side.

B. For Male:
1. Retract foreskin and gently cleanse glans penis with a cotton ball moistened
with soap and water.
2. Use a new cotton ball on each side.
14. Check cord and dress infant.
15. Document the procedure done.
C. ATTITUDE
16. Shows responsibility by having a complete set of equipment needed in the activity and
shows interest in doing the procedure.
17. Displays courtesy and consideration in acknowledging criticisms and suggestions by
the Clinical Instructor.
18. Demonstrates integrity by doing the skill honestly, competently and completely.

A. Knowledge - Total score / Total no of items x 60 + 40 = _____x .3= ______________

B. Skills - Total score / Total no of items x 60 + 40 = _____x .6= ______________

C. Attitude - Total score / Total no of items x 60 + 40 = _____x .1= ______________

TOTAL = ___________________

Clinical Instructor’s Comments / Suggestions:

_____________________________________________________________________________________________.

Students’ Comments / Suggestions:

_____________________________________________________________________________________________.

Danica Mae B. Bianito _________________________

Student’s name & signature C.I.’s name & signature