NARM Examination Test Specifications

The Test Specifications were developed from a recent Job Analysis which was based on the Midwives’ Alliance of North America (MANA) Core Competencies. NARM strongly urges all candidates to thoroughly review the NARM Examination test specifications and their associated reference lists to prepare for successful completion of the CPM Certification Examination process. NARM considers the test specifications to be the essential curriculum for entry-level midwives.

CPM NARM Examination Matrix

Written Test Specifications, rev 2017

I. Professional Issues, Knowledge, and Skills (5% of Exam - 12-18 Examination Items)

1. Applies understanding of social determinants of health (income, literacy, education, sanitation, housing, environmental hazards, food security, common threats to health)
2. Applies understanding of direct and indirect causes of maternal and neonatal mortality and morbidity
3. Understands principles of research, evidence-based practice, critical interpretation of professional literature, and interpretation of vital statistics and research findings
4. Provides information on national and local health services, such as social services, WIC, breastfeeding, substance abuse, mental health, and bereavement
5. Educates about resources for referral to higher health facility levels, appropriate communication and transport mechanisms, prepared for emergencies
6. Knows legal and regulatory framework governing reproductive health for women, including laws, policies, protocols, and professional guidelines
7. Applies understanding of human rights and their effects on the health of individuals, including:
   1. domestic partner violence
   2. female genital cutting
   3. cultural effect of religious beliefs
   4. gender roles
   5. other cultural health practices
8. Facilitates mother’s decision of where to give birth by discussing:
   1. advantages and risks of different birth sites
   2. requirements of the birth site
   3. how to prepare and equip the birth site
9. Participates in peer review for maternal and neonatal mortality or morbidity
   1. understands the purpose of peer review
   2. understands the process of participating in peer review
10. Understands the application of professional ethics, values, and human rights
    1. understands and applies the principles of confidentiality in relationships with clients and students including applicable components of HIPAA
    2. understands the process of shared decision making with clients throughout pregnancy and birth

II. General Healthcare Skills (5% of Exam - 12-18 Examination Items)

1. Demonstrates the application of Universal Precautions as they relate to midwifery:
   1. handwashing
   2. gloving and ungloving
   3. sterile technique
2. Educates on the benefits and contraindications of alternative healthcare practices (non-allopathic treatments) and modalities, including herbs, hydrotherapy, waterbirth, chiropractic, homeopathic, and acupuncture
3. Understands the benefits and risks, and recommends the appropriate use of vitamin and mineral supplements, including prenatal multi-vitamins, Vitamin C, Vitamin E, Folic acid, B-complex, B-6, B-12, iron, calcium, magnesium, probiotics, and Vitamin D
4. Demonstrates knowledge of the benefits and risks and appropriate administration of the following pharmacological (prescriptive) agents:
   1. local anesthetic for suturing
   2. medical oxygen
   3. Methergine ® (methylergonovine maleate)
   4. prescriptive ophthalmic ointment
   5. Pitocin ® for postpartum hemorrhage
   6. RhoGam ®
   7. Vitamin K (oral or IM)
   8. antibiotics for Group B Strep
   9. IV fluids
   10. Cytotec ® (misoprostol)
   11. Epinephrine
5. Demonstrates knowledge of benefits/risks of ultrasounds for indications such as pregnancy dating, anatomy scan, AFL, fetal well-being and growth, position, placental position, and determination of multiples
6. Demonstrates knowledge of benefits/risks of biophysical profile, including counseling and referrals
7. Demonstrates knowledge of how and when to use instruments and equipment, including:
   1. amnihook
   2. bag and mask resuscitator
   3. bulb syringe
   4. Delee ® tube-mouth suction device
   5. hemostats
   6. lancets
   7. nitrazine paper
   8. scissors (all kinds)
   9. suturing equipment
   10. straight, in and out catheter
   11. vacutainer /blood collection tube
   12. gestational wheel or calendar
   13. newborn and adult scale
   14. thermometer
   15. urinalysis strips
   16. cord clamps
   17. doppler
   18. fetoscope
   19. stethoscope
   20. vaginal speculum
   21. blood pressure cuff
   22. oxygen tank, flow meter, cannula, and face mask
   23. pulse oximeter
   24. laryngeal mask airway (LMA)
8. Proper use of injection equipment including syringe, single and multi dose vial/ampules, and sharps container
9. Obtains or refers for urine culture
10. Obtains or refers for vaginal culture
11. Obtains or refers for blood screening tests
12. Evaluates laboratory and medical records, with appropriate education and counseling of client, including:
    1. hematocrit/hemoglobin
    2. blood sugar (glucose)
    3. HIV
    4. Hepatitis B
    5. Hepatitis C
    6. Rubella
    7. Syphilis (VDRL or RPR)
    8. Group B Strep
    9. Gonorrhea culture
    10. Complete Blood Count
    11. Blood type and Rh factor
    12. Rh antibodies
    13. Chlamydia
    14. PAP test
    15. Vitamin D
    16. thyroid panel
    17. HbA1c
    18. genetic screening
    19. blood albumin
    20. complete metabolic panel
    21. progesterone
    22. HCG

III. Maternal Health Assessment (10% of Exam - 24-36 Examination Items)

1. Obtains and maintains records of health, reproductive and family medical history and possible implications to current pregnancy, including:
   1. personal information/demographics including religion, occupation, education, marital status, and economic status
   2. increased risk for less-than-optimal outcomes due to allostatic stress from racism and resource scarcity
   3. changes in health or behavior, and woman’s evaluation of her health and nutrition
   4. potential exposure to environmental toxins
   5. medical conditions
   6. surgical history
   7. reproductive history, including:
      1. menstrual history
      2. gynecologic history
      3. sexual history
      4. childbearing history
      5. contraceptive practice
      6. history of sexually transmitted infections
      7. history of behavioral risk factors for sexually transmitted infection
      8. history of risk of exposure to blood borne pathogens
      9. Rh type and plan of care if negative
   8. family medical history
   9. psychosocial history
   10. history of abuse
   11. mental health
   12. Mother’s medical history
       1. Genetics
       2. alcohol use
       3. drug use
       4. tobacco use
       5. allergies (environmental & medical)
       6. history of vasovagal response or fainting
       7. foreign travel history
       8. vaccination history/status
   13. Father’s medical history
       1. genetics
       2. alcohol use
       3. drug use
       4. tobacco use
2. Performs a physical examination, including assessment of:
   1. size of uterus and ovaries by bimanual exam
   2. general appearance/skin condition
   3. baseline weight and height
   4. vital signs
   5. HEENT (Head, Eyes, Ears, Nose, and Throat) including thyroid by palpation
   6. lymph glands of neck, chest, and under arms
   7. breasts, including mother’s knowledge of self breast exam techniques
   8. torso, extremities for bruising, abrasions, moles, unusual growths
   9. baseline reflexes
   10. heart and lungs
   11. abdomen by palpation and observation for scars
   12. kidney pain (CVAT)
   13. deep tendon reflexes of the knee
   14. condition of the vulva, vagina, cervix, perineum, and anus
   15. cervix by speculum exam
   16. vascular system (edema, varicosities, thrombophlebitis

IV. Prenatal Care (25% of Exam - 69-81 Examination Items)

1. Provides appropriate prenatal care and educates the family of significance
2. Understands and educates about the anatomy and physiology of pregnancy and birth
3. Understands normal and abnormal changes during pregnancy
4. Assesses results of routine prenatal exams including ongoing assessment of:
   1. maternal psycho-social, emotional health and well being; signs of abuse
   2. vaginal discharge; including signs and symptoms of infection
   3. social support system
   4. maternal health by tracking variations and changes in:
      1. blood pressure
      2. weight
      3. color of mucus membranes
      4. general reflexes
      5. elimination/urination patterns
      6. sleep patterns
      7. energy levels
      8. nutritional patterns, pica
      9. hemoglobin/hematocrit
      10. glucose levels
      11. breast conditions/implications for breastfeeding
   5. Assesses urine for:
      1. appearance: color, density, odor, clarity
      2. protein
      3. glucose
      4. ketones
      5. pH
      6. leukocytes
      7. nitrites
      8. blood
      9. specific gravity
   6. Estimates due date based on standard methods
   7. Assesses fetal growth and wellbeing
      1. fetal heart rate/tones auscultated with fetoscope or Doppler
      2. correlation of weeks gestation to fundal height
      3. fetal activity and responsiveness to stimulation
   8. Fetal palpation for:
      1. fetal weight
      2. fetal size
      3. fetal lie
      4. degree of fetal head flexion
   9. Clonus
   10. Vital signs
   11. Respiratory assessment
   12. Edema
   13. Provides prenatal education, counseling, and recommendations for:
       1. nutritional and non-allopathic dietary supplement support
       2. normal body changes in pregnancy
       3. exercise and movement
       4. weight gain in pregnancy
       5. common complaints of pregnancy:
          1. sleep difficulties
          2. nausea/vomiting
          3. Fatigue
          4. inflammation of sciatic nerve
          5. breast tenderness
          6. skin itchiness
          7. vaginal yeast infection
          8. bacterial vaginosis
          9. symptoms of anemia
          10. indigestion/heartburn
          11. constipation
          12. hemorrhoids
          13. carpal tunnel syndrome
          14. round ligament pain
          15. headache
          16. leg cramps
          17. backache
          18. varicose veins
          19. sexual changes
          20. emotional changes
          21. fluid retention/swelling, edema
5. Recognizes and responds to potential prenatal complications/variations by identifying, assessing, recommending treatment, or referring for:
   1. antepartum bleeding (first, second, or third trimester)
   2. pregnancy inducted hypertension
   3. pre-eclampsia
   4. gestational diabetes
   5. urinary tract infection
   6. fetus small for gestational age
   7. fetus large for gestational age
   8. intrauterine growth retardation
   9. thrombophlebitis
   10. oligohydramnios
   11. polyhydramnios
   12. breech presentation:
       1. identifying breech presentation
       2. turning breech presentation with:
          1. alternative positions (tilt board, exercises, etc.)
          2. referral for external version
          3. non-allopathic methods (moxibustion, homeopathic)
       3. management strategies for unexpected breech delivery
   13. multiple gestation:
       1. identifying multiple gestation
       2. management strategies for unexpected multiple births
   14. Occupit posterior position:
       1. identification
       2. prevention
       3. techniques to encourage rotation
   15. vaginal birth after cesarean (VBAC)
       1. identifies VBAC by history and physical
       2. indications/contraindications for out-of-hospital births
       3. management strategies for VBAC
       4. identifies risk factors for uterine rupture:
          1. type of uterine suturing
          2. uterine incision (classical or transverse)
          3. uterine scar thickness
          4. interdelivery interval
          5. number of previous cesareans
          6. previous vaginal births
          7. implantation site of placenta
   16. recognizes signs, symptoms of uterine rupture and knows emergency treatment
   17. preventing pre-term birth:
       1. risk assessment for pre-term birth
          1. smoking
          2. vaginal or urinary tract infections
          3. periodontal health
          4. prior pre-term birth
          5. other factors: stress, emotional health
       2. educates and counsels mothers who request early induction of labor
       3. educates for signs of pre-term labor
   18. identifies and deals with pre-term labor with:
       1. referral
       2. consults for pre-term labor
       3. treats pre-term labor with standard measures
   19. assesses and evaluates a post-date pregnancy by monitoring/assessing:
       1. fetal movement, growth, and heart tone variability
       2. estimated due date calculations
       3. previous birth patterns
       4. amniotic fluid volume
       5. maternal tracking of fetal movement
       6. consults or refers for:
          1. ultrasound
          2. non-stress test
          3. biophysical profile
   20. standard measures for treating a post-date pregnancy
   21. Cholestasis
   22. conditions from previous pregnancies such as diastasis, prolapse, cyctocele, rectocele
   23. identifies and refers for:
       1. tubal, molar, or ectopic pregnancy
       2. placental abruption
       3. placenta previa
   24. identifies premature rupture of membranes
   25. manages premature rupture of membranes in a FULL-TERM pregnancy:
       1. monitors fetal heart tones and movement
       2. minimizes internal vaginal examinations
       3. reinforces appropriate hygiene techniques
       4. monitors vital signs for infection
       5. encourages increased fluid intake
       6. supports nutritional/non-allopathic treatment
       7. stimulates labor
       8. consults for prolonged rupture of membranes
       9. reviews Group B Strep status and inform of options
   26. consults and refers for premature rupture of membranes in a PRE-TERM pregnancy
   27. establishes and follows emergency contingency plans for mother/baby
   28. educates on options for hospital transport, including augmentation and pharmacological pain relief
   29. cesarean birth:
       1. knows local options for cesarean birth
       2. educates on procedures for cesarean birth
       3. provides support before, during (as permitted), and after the cesarean process
       4. follows up for cesarean birth, including:
          1. physical healing
          2. emotional healing
          3. breastfeeding and infant care after cesarean birth

V. Labor, Birth, and Immediate Postpartum (35% of Exam - 99-111 Examination items)

1. Understands and supports the normal physiological process of labor and birth
2. Understands the relationship of maternal and fetal anatomy in relation to labor and birth
3. Facilitates maternal relaxation and provides comfort measures throughout labor:
   1. applies knowledge of emotional and psychological aspects of labor to provide support
   2. applies knowledge of physical support in labor (counter pressure, position changes, massage, water, etc.)
   3. waterbirth
      1. educates on benefits and risks of waterbirth
      2. equips the birth site for a waterbirth
      3. discusses specific management of complications during waterbirth
4. Recognizes and counsels on signs of early labor and appropriate activities
5. Assesses maternal and infant status based on:
   1. vital signs
   2. food and fluid intake
   3. status of membranes
   4. uterine contractions (frequency, duration, intensity)
   5. fetal heart tones
   6. fetal lie, presentation, position, and descent
   7. cervical effacement and dilation
6. Assesses and supports normal progress of labor
7. Recognizes and responds appropriately to conditions that slow or stall labor, such as:
   1. anterior/swollen lip
   2. posterior or asynclitic fetal position
   3. pendulous belly inhibiting descent
   4. maternal exhaustion
   5. maternal fears, emotions
   6. abnormal labor patterns
   7. deep transverse arrest
   8. obstructed labor
   9. advises on non-allopatic remedies (nipple stimulation, herbs, positions, movement, etc.)
8. Recognizes, prevents or treats maternal dehydration
9. Recognizes and responds to labor and birth complications such as:
   1. abnormal fetal heart tones and patterns
   2. cord prolapse
   3. recognizes and responds to variations in presentations, such as:
      1. breech
         1. understands mechanism of descent and rotation for complete, frank, or footling breech presentation
         2. techniques for release of nuchal arms with breech
      2. nuchal hand/arm
         1. applies counter pressure to hand or arm and perineum
         2. sweeps arm out
      3. nuchal cord
         1. loops finger under cord, sliding over heard or shoulder
         2. clamps and cuts cord
         3. presses baby’s head into perineum and somersaults the baby out
         4. prepares for possible resuscitation
      4. face and brow
         1. mechanism of delivery for face or brow presentation
         2. determines position of chin
         3. management strategies for face or brow presentation
         4. prepares for resuscitation or treatment of bruising/swelling/ eye injury
   4. multiple birth and delivery
      1. identifies multiple gestation
      2. consults or transports according to plan
      3. prepares for attention to more than one
   5. shoulder dystocia
      1. applies gentle traction while encouraging pushing
      2. repositions the mother to:
         1. hands and knees (Gaskin maneuver)
         2. exaggerated lithotomy (McRobert’s position)
         3. end of bed
         4. squat
      3. repositions shoulders to oblique diameter
      4. shifts pelvic angle with lunge or runner’s pose
      5. extracts posterior arm
      6. flexes shoulders of newborn, then corkscrews
      7. applies supra-pubic pressure
      8. sweeps arm across newborn’s face
      9. fractures baby’s clavicle
   6. indications for performing an episiotomy
   7. management of meconium stained fluids
      1. recognizes and assesses degree of meconium
      2. follows standard resuscitation procedures for meconium
   8. management of maternal exhaustion:
      1. hydration and nutrition
      2. rest/bath/removal of distractions
      3. monitors maternal and fetal vital signs, including urine ketones
      4. evaluates for consultation or referral
   9. recognizes/consults/transports for signs of:
      1. uterine rupture
      2. uterine inversion
      3. amniotic fluid embolism
      4. stillbirth
10. Evaluates and supports during second stage:
    1. recognizes and assesses progress in second stage
    2. supports maternal instincts in pushing techniques and positions
    3. recommends/suggests pushing techniques and positions when needed
    4. monitors vital signs; understands normal and abnormal changes
    5. facilitates supportive environment and family involvement
    6. prepares necessary equipment for immediate access
    7. uses appropriate hand techniques for perineal support and birth of baby
11. Assesses condition and provides immediate care of newborn
    1. understands, recognizes, and supports normal newborn adjustment at birth
       1. keeps mother and baby warm and together for initial assessment
       2. determines APGAR score at one minute, five minutes, and, if needed, at ten minutes
       3. monitors respiratory and cardiac function by assessing:
          1. symmetry of chest
          2. sound and rate of heart tones and respirations
          3. nasal flaring
          4. grunting
          5. chest retractions
          6. circumoral cyanosis
          7. central cyanosis
       4. stimulates newborn respiration according to AAP/NRP recommendations
       5. encourages parental touch and speech while keeping baby warm
    2. responds to need for newborn resuscitation according to AAP/NRP recommendations
    3. recognizes and consults or transports for apparent birth defects
    4. recognizes signs and symptoms of Meconium Aspiration Syndrome and consults or transports
    5. provides appropriate care of the umbilical cord:
       1. clamps and cuts cord after pulsing stops
       2. evaluates the cord, including number of vessels
       3. collects cord blood sample if needed
    6. assesses gestational age
    7. assesses for central nervous system disorder
12. Recognizes and responds to normal third stage, including physiological and active management strategies
    1. determines signs of placental separation such as:
       1. separation gush
       2. contractions
       3. lengthening of cord
       4. urge to push
       5. rise in fundus
    2. facilitates delivery of the placenta by:
       1. breast feeding/nipple stimulation
       2. changing maternal position
       3. performing guarded cord traction
       4. emptying the bladder
       5. administering non-allopathic treatments
       6. encouraging maternal awareness
       7. manual removal
       8. transport for removal
13. Assesses condition of placenta and membranes, recognizes normal and abnormal characteristics
14. Estimates and monitors ongoing blood loss
    1. responds to a trickle bleed by:
       1. assesses origin
       2. assesses fundal height and uterine size
       3. fundal massage
       4. assesses vital signs
       5. emptying bladder
       6. breastfeeding or nipple stimulation
       7. expressing clots
       8. non-allopathic treatments
15. Responds to postpartum hemorrhage with:
    1. fundal massage
    2. external bimanual compression
    3. internal bimanual compression
    4. manual removal of clots
    5. administering medications
    6. non-allopathic treatments
    7. increasing maternal focus and participation
    8. administering or referin for IV fluids
    9. consulting and/or transfer; activating emergency back up plan
    10. treating for hypovolemic shock according to standard recommendations or protocols
    11. performing external aortic compression
16. Assesses general condition of mother
    1. assesses for bladder distension
       1. encourages urination
       2. performs catheterization if needed
    2. assesses condition of vagina, cervix, and perineum for:
       1. Cystocele
       2. Rectocele
       3. Hematoma
       4. Hemorrhoids
       5. Bruising
       6. prolapsed cervix or uterus
       7. tears, lacerations:
          1. assesses blood color and volume; identify source
          2. applies direct pressure on tear
          3. clamps vessel; if identified
          4. sutures 1st or 2nd degree or labial tears
          5. administers local anesthetic
          6. performs suturing according to standard procedures and protocols
          7. provides alternative repair methods (non-suturing)
    3. provides instructions on care and treatment of perineum
    4. monitors maternal vital signs after birth
    5. provides timely food and drink
17. Facilitates breastfeeding by assisting and teaching about:
    1. Colostrum
    2. positions for mother and baby
    3. skin to skin contact
    4. latching on
    5. maternal hydration and nutrition
    6. maternal rest
    7. feeding patterns
    8. maternal comfort measures for engorgement
    9. letdown reflex
    10. milk expression
    11. normal newborn urine and stool output
18. Performs a newborn exam by assessing for normal and abnormal
    1. assesses the head for:
       1. size/circumference
       2. molding
       3. hematoma
       4. caput
       5. suture lines
       6. Fontanels
    2. assesses the eyes for:
       1. jaundice
       2. pupil condition
       3. tracking
       4. spacing
       5. clarity
       6. hemorrhage
       7. discharge
       8. red eye reflex
    3. assesses the ears for:
       1. positioning
       2. response to sound
       3. patency
       4. Cartilage
    4. assesses the mouth for:
       1. appearance and feel of palate
       2. lip and mouth color
       3. tongue
       4. lip cleft
       5. signs of dehydration
       6. tongue and lip tie
    5. assesses the nose for:
       1. patency
       2. flaring nostrils
    6. assesses the neck for:
       1. enlarged glands, thyroid, and lymph
       2. trachea placement
       3. soft tissue swelling
       4. unusual range of motion
    7. assesses the clavicle for:
       1. integrity
       2. symmetry
    8. assesses the chest for:
       1. symmetry
       2. nipples
       3. breast enlargement or discharge
       4. measurement (chest circumference)
       5. heart sounds (rate and irregularities)
    9. auscultates the lungs, front and back, for:
       1. breath sounds
       2. equal bilateral expansion
    10. assesses the abdomen for:
        1. enlarged organs
        2. masses
        3. hernias
        4. bowel sounds
        5. rigidity
    11. assesses the groin for:
        1. femoral pulses
        2. swollen glands
    12. assesses the genitalia for:
        1. appearance
        2. position of urethral opening
        3. testicles for:
           1. descent
           2. rugae
           3. herniation
        4. assesses the labia for:
           1. patency
           2. maturity of clitoris and labia
        5. assesses the rectum for:
           1. patency
           2. meconium
    13. assesses abduct hips for dislocation
    14. assesses the legs for:
        1. symmetry of creases in the back of legs
        2. equal length
        3. foot/ankle abnormality
    15. assesses the feet for:
        1. abnormalities
        2. digits: number, webbing
        3. creases
    16. assesses the arms for symmetry in:
        1. structure
        2. movement
    17. assesses the hands for:
        1. digits: number, webbing
        2. finger taper
        3. palm creases
        4. length of nails
    18. assesses the backside of the baby for:
        1. symmetry of hips, range of motion
        2. condition of the spine:
           1. dimpling
           2. holes
           3. straightness
    19. assesses flexion of extremities and muscle tone
    20. assesses reflexes:
        1. sucking
        2. moro
        3. babinski
        4. plantar/palmar
        5. stepping
        6. grasping
        7. rooting
        8. blinking
    21. assesses skin condition for:
        1. color
        2. lesions
        3. birthmarks
        4. milia
        5. vernix
        6. lanugo
        7. peeling
        8. rashes
        9. bruising
        10. Mongolian spots
    22. assesses length of baby
    23. assesses weight of baby
    24. assesses temperature of the baby
19. Assesses gestational age of the baby
20. Administers eye prophylaxis with informed consent of parents
21. Administers Vitamin K with informed consent of parents
22. Reviews Group B Strep status and signs or symptoms and plans for follow-up

VI. Postpartum (15% of Exam - 39-51 Items)

1. Assesses and evaluates physical and emotional changes following childbirth, including normal process of involution
2. Assesses and evaluates normal or abnormal conditions of mother or baby at:
   1. day one to day two
   2. day three to day four
   3. one to two weeks
   4. three to four weeks
   5. five to six weeks
3. Assesses and provides counseling and education for:
   1. postpartum subjective history
   2. lochia vs. abnormal bleeding
   3. return of menses
   4. vital signs, digestion, elimination patterns
   5. muscle prolapse of vagina and rectum (cystocele, rectocele)
   6. condition and strength of pelvic floor
   7. condition of uterus (size and involution) ovaries, and cervix
   8. condition of vulva, vagina, perineum, and anus
   9. facilitates psycho-social adjustment:
      1. recognizes and responds to mild postpartum depression
      2. counsels for appropriate support from family and friends
      3. increases home or phone visits as needed
      4. recognizes and responds to increased severity of postpartum depression or psychosis
      5. counsels client and family on resources for depression; increases follow-up
4. Knows signs and symptoms, differential diagnosis, and appropriate midwifery management or referral for:
   1. uterine infection
   2. urinary tract infection
   3. infection of vaginal tear or incision
   4. postpartum bleeding/hemorrhage
   5. thrombophlebitis
   6. separation of abdominal muscles
   7. separation of symphasis pubis
   8. postpartum pre-eclampsia
5. Evaluates and counsels for newborn jaundice
   1. refers or consults for jaundice in the first 24 hours after birth
   2. evaluates, counsels, and monitors for physiological jaundice after 24 hours
   3. encourages mother to breastfeed every two hours
   4. exposes front and back of newborn to sunlight through window glass
   5. assesses and monitors newborn lethargy and hydration
   6. consults or refers for increased symptoms
6. Provides direction for care of circumcised penis
7. Provides direction for care of intact (uncircumcised) penis
8. Breastfeeding care and counseling:
   1. educates regarding adverse factors affecting breastfeeding or breastmilk
      1. environmental
      2. biological
      3. occupational
      4. pharmacological
   2. evaluates baby’s sucking method, position of lips and tongue
   3. evaluates conditions of breasts and nipples
   4. treats sore nipples:
      1. exposure to air
      2. alternates nursing positions
      3. applying topical agents
      4. applying expressed breastmilk
      5. flange of lips
      6. latch on
      7. tongue tie
      8. sucking
      9. swallowing
   5. treats thrush on nipples:
      1. dries nipples after nursing
      2. non-allopathic remedies
      3. allopathic treatments
   6. treats mastitis by:
      1. provides immune support including:
         1. nutrition/hydration
         2. non-allopathic remedies
      2. encourages multiple nursing positions
      3. applies herbal/non-allopathic compresses
      4. applies warmth, soaking in tub or by shower
      5. encourages adequate rest/relaxation
      6. assesses for signs and symptoms of infection
      7. teaches mother to empty breasts at each feeding
      8. provides or teaches gentle massage of sore spots
      9. consults or refers to breastfeeding support groups, lactation counselor, or other healthcare providers
9. Provides contraceptive and family planning education, counseling, and referrals
10. Provides opportunity for verbal and written feedback from client

VII. Well-Baby Care (5% of Exam - 12-18 Items)

1. Provides newborn care up to six weeks
2. Principles of newborn adaptation to extrauterine life (physiologic changes in pulmonary and cardiac systems)
   1. Basic needs of newborn (breathing, warmth, nutrition, and bonding)
   2. Normal/abnormal newborn activity, responses, vital signs, appearance, behavior, etc.
   3. Normal growth and development of the newborn and infant
3. Assesses the current health and appearance of baby including:
   1. temperature
   2. heart rate, rhythm, and regularity
   3. respirations
   4. appropriate weight gain
   5. length
   6. measurement of circumference of head
   7. neuro-muscular response
   8. level of alertness
   9. wake/sleep cycles
   10. feeding patterns
   11. urination and stool for frequency, quantity, and color
   12. appearance of skin
   13. jaundice
   14. condition of cord
4. Understands, respects, and counsels on traditional or cultural practices related to the newborn
5. Advises mother in care of:
   1. diaper rash
   2. cradle cap
   3. heat rash
   4. colic
   5. cord care
6. Recognizes signs/symptoms and differential diagnosis of:
   1. infections
   2. cardio-respiratory abnormalities
   3. glucose disorders
   4. birth defects
   5. failure to thrive
   6. newborn hemorrhagic disease (early and late onset)
   7. polycythemia
   8. non-accidental injuries
   9. dehydration
7. Evaluates, counsels, and monitors for physiological jaundice after 24 hours
   1. encourages mother to breastfeed every two hours
   2. exposes front and back of newborn to sunlight through window glass
   3. assesses and monitors newborn lethargy and hydration
   4. consults or refers for additional screening and/or treatment
8. Provides information for referral for continued well-baby care
   1. performs or refers for newborn metabolic screening
   2. performs or refers for hearing screening
   3. performs or refers for pulse oximetry newborn screening for congenital heart disease (CCHD)
   4. educates about referral for integrative/complimentary/alternative practitioners
   5. educates about options for pediatrician or family practitioner
   6. educates about health care providers for immunizations or non-immunizations
9. Supports and educates parents during grieving process for loss of pregnancy, stillbirth congenital birth defects, or neonatal death
10. Supports and educates parents of newborns transferred to hospital or with special needs
11. Supports integration of baby into family