Newborn Measurement guide

To ensure neonatal stability and monitor for any changes.

Work Procedures

First: Respiration

• Respiratory rate is assessed first, before other vital signs, to avoid stimulation that may lead to inaccurate readings.

Equipment:

• Stopwatch

Steps:

• Perform routine hand hygiene.
• Prepare the equipment.
• Approach the neonate quietly and observe respiration from outside the incubator without touching or moving the neonate.
• Count respirations for a full minute by observing abdominal movement.
• Document the respiratory rate, rhythm, depth, and type.
• Notify the physician of any abnormal findings.
• Normal neonatal respiratory rate ranges from 40–60 breaths/minute.

Second: Heart Rate

• Heart rate is assessed before temperature measurement, as temperature assessment may disturb the neonate and elevate the heart rate.

Equipment:

• Stethoscope
• Stopwatch
• Cotton pieces moistened with 70% ethyl alcohol
• Waste bin with red bag

Steps:

• Perform routine hand hygiene.
• Prepare the equipment.
• Disinfect the stethoscope diaphragm with an alcohol swab.
• Warm the stethoscope in the palm before contact with the neonate’s skin.
• Place the stethoscope over the apical area, just below the left nipple between the fourth and fifth intercostal spaces.
• Count heartbeats for a full minute, noting strength and regularity.
• Normal heart rate ranges from 120–160 beats/minute.
• Clean the stethoscope with alcohol.
• Return equipment to its place.
• Perform routine hand hygiene.
• Document the reading and notify the physician of any abnormal findings.

Third: Temperature

Equipment:

• Rectal thermometer (if measuring rectally)
• Petroleum jelly or paraffin oil (for rectal measurement)
• Cotton pieces moistened with 70% ethyl alcohol
• Waste bin with red bag

Rectal Temperature Measurement Steps

• Perform routine hand hygiene.
• Prepare the equipment.
• Wash the thermometer with cold water and soap, rinse and dry thoroughly.
• Disinfect the thermometer with an alcohol swab from the mercury reservoir to the tip.
• Shake the thermometer until the mercury level falls below 35°C.
• Apply a thin layer of petroleum jelly or paraffin oil to the tip.
• Place the neonate in a supine position and loosen the diaper.
• Hold the neonate’s ankles, flexing the knees upward.
• Gently insert the thermometer into the rectum at a 30-degree angle downward and backward, applying gentle pressure to the buttocks to prevent expulsion.
• Keep the thermometer in place for one minute, then remove and clean.
• Read the temperature.
• Normal rectal temperature ranges from 36.5–37.5°C.
• Refasten the diaper and allow the neonate to rest.
• Clean, disinfect, and store the thermometer properly.
• Clean and return equipment to its place.
• Perform routine hand hygiene.
• Document the temperature in the neonate’s chart.

Note:
Rectal temperature measurement should be avoided unless other methods are not feasible. Proper technique must be followed to prevent complications.

Axillary Temperature Measurement Steps

• Perform routine hand hygiene.
• Disinfect the thermometer with an alcohol swab.
• Place the neonate in a supine position.
• Position the thermometer vertically in the center of the axilla.
• Secure the neonate’s arm against the body to hold the thermometer in place.
• Maintain the position for at least 5 minutes, ensuring continuous observation.
• Remove the thermometer and read the temperature.
• Return the neonate to the pre-measurement position.
• Perform routine hand hygiene.
• Document the temperature in the neonate’s chart.
• Return equipment to its place.

Fourth: Blood Pressure

Equipment:

• Cardiorespiratory monitor with blood pressure cuff
• Cotton pieces moistened with 70% ethyl alcohol
• Waste bin with red bag

Steps:

• Perform routine hand hygiene.
• Select the appropriate cuff size (should not cover more than two-thirds of the upper arm length).
• Disinfect the cuff using 70% alcohol.
• Wrap the cuff around the upper arm just above the elbow.
• Activate automatic cuff inflation.
• Observe the monitor until the reading appears.
• Document systolic, diastolic, and mean arterial pressure, and notify the physician of any abnormal readings.
• Disinfect the cuff with 70% ethyl alcohol.
• Perform routine hand hygiene.

Responsible:

• Nursing staff.