Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
IV THERAPY
Start peripheral IV 0 1 2
Mixing IV’s 0 1 2
Drawing blood from central line 0 1 2
Drawing venous blood 0 1 2
IMED pumps 0 1 2
IVAC pumps 0 1 2
Maintain central lines 0 1 2
PCA pumps 0 1 2
Administration of Blood Products
Albumin/Plasma 0 1 2
Cyroprecipitate 0 1 2
RBC 0 1 2
Whole blood 0 1 2
ANTEPARTUM - Assessment
Breathing 0 1 2
Coaching 0 1 2
Comfort 0 1 2
Positioning 0 1 2
Equipment & Procedures
Foley Catheter 0 1 2
Delivery table set-up 0 1 2
Equipment & Procedures - Sonogram
Amniotic fluid index 0 1 2
Assist with sonogram 0 1 2
Biophysical profile 0 1 2
Perform Sonogram 0 1 2
LABOR ASSESSMENT / FETAL ASSESSMENT
Auscultate fetal heart rate with doppler 0 1 2
Auscultate fetal heart rate with fetoscope 0 1 2
Determine fetal position 0 1 2
Document FHR patterns 0 1 2
Identify normal & treat abnormal FHR patterns
Baseline 0 1 2
Early decelerations 0 1 2
Late decelerations 0 1 2
Prolonged decelerations 0 1 2
Variable decelerations 0 1 2
LABOR ASSESSMENT / MATERNAL ASSESSMENT
Deep tendon reflexes (DTRs) 0 1 2
Edema 0 1 2
Norms for perinatal vital signs 0 1 2
Perform admission risk assessment 0 1 2
Presence of clonus 0 1 2
Admission Vaginal Exam
Station 0 1 2
Effacement/dilation 0 1 2
Presenting part 0 1 2
Progression of Labor
Contraction characteristics 0 1 2
Dilation 0 1 2
Effacement 0 1 2
Fetal presentation/position 0 1 2
Station 0 1 2
Status of membranes 0 1 2
Sterile speculum exam 0 1 2
Vaginal exam 0 1 2
Rupture of Membranes
Fern test 0 1 2
Nitrazine 0 1 2
LABOR ASSESSMENT - Equipment & Procedures
Amnioinfusion (assist or perform
for meconium) 0 1 2
Amnioinfusion (assist or perform for
variable decelerations) 0 1 2
Artificial Rupture of Membranes (Assist)
Prolapsed cord 0 1 2
Recognize potential complications 0 1 2
Vasa previa 0 1 2
Collect blood/urine specimens 0 1 2
Collect Vaginal Cultures
Chlamydia 0 1 2
Fluid
Group B strep 0 1 2
Herpes 0 1 2
LABOR ASSESSMENT - Document Labor Status
Assessments & Interventions
Anticonvulsants 0 1 2
Labor suppressants 0 1 2
Perform Leopold’s maneuvers 0 1 2
External Fetal - Application
Doppler 0 1 2
Phono or abdomina, ECG transducer 0 1 2
Tocotransducer, ultrasound 0 1 2
(Assists or Perform Insertion)
Intrauterine pressure catheter-fluid filled 0 1 2
Intrauterine pressure catheter-transducer
tipped 0 1 2
Spiral electrode 0 1 2
Toxicology studies 0 1 2
Medications
IM 0 1 2
SC 0 1 2
IV Antibiotics 0 1 2
Heparin 0 1 2
Magnesium sulfate 0 1 2
Oxytocin 0 1 2
Assist with prostin gel 0 1 2
Cervidil insertion 0 1 2
Use of Cytotec 0 1 2
Use of prostin suppositories 0 1 2
Examination of placental/membrane/cord 0 1 2
Disposal of placenta 0 1 2
PREGNANCY - Complications / Assessment
Identify common arrhythmias 0 1 2
Normal cardiac rhythms 0 1 2
Patient education-fetal movement counts 0 1 2
Equipment & Procedures
Assist with external version 0 1 2
Assist with fetal scalp sampling 0 1 2
Complications - Equipment & Procedures)
Assist with percutaneous umbilical sampling 0 1 2
Set-up for Cesarean delivery 0 1 2
Circulate for Cesarean delivery 0 1 2
Scrub for Cesarean delivery 0 1 2
Circulate for bilateral tubal ligation 0 1 2
Scrub for bilateral tubal ligation 0 1 2
PREGNANCY - Interventions - Anesthesia
Breast stimulation 0 1 2
Anesthesia toxicity 0 1 2
Coaching patient 0 1 2
Epidural block 0 1 2
Fluid challenge 0 1 2
Hypotension 0 1 2
Intrathecal narcotics 0 1 2
Intravascular injection 0 1 2
Positioning patient 0 1 2
Signs/symptoms of dural puncture 0 1 2
Spinal anesthesia 0 1 2
Documentation of anesthesia 0 1 2
Conduct Contraction Stress Test
Oxytocin challenge 0 1 2
Conduct Non-Stress Test
Stimulate the fetus 0 1 2
Vibroacoustic stimulation 0 1 2
Draw umbilical blood samples 0 1 2
Glucose reflectometer 0 1 2
Lines/Monitoring
CVP 0 1 2
Invasive hemodynamic monitoring 0 1 2
PICC 0 1 2
Pulmonary artery catheters 0 1 2
Care of Patient
Abruptio placenta 0 1 2
Asthma 0 1 2
Cardiac disease 0 1 2
Chorioamnionitis 0 1 2
Chronic hypertension 0 1 2
Collagen vascular disease 0 1 2
Diabetes 0 1 2
Eclampsia 0 1 2
HBV 0 1 2
HELLP syndrome 0 1 2
Hemolytic anemia’s 0 1 2
Hemorrhage 0 1 2
HIV postive 0 1 2
PREGNANCY - Complications - Care of Patient (CONT)
Hypertension 0 1 2
Malpresentations 0 1 2
Multiple gestation 0 1 2
Placentia previa 0 1 2
Preeclampsia 0 1 2
Premature labor 0 1 2
Pyelonephritis 0 1 2
RH disease 0 1 2
Sickle cell anemia 0 1 2
Care of Patient
Indomethacin 0 1 2
Insulin 0 1 2
Magnesium sulfate 0 1 2
Procardia 0 1 2
Ritordrine 0 1 2
Terbutaline-IV 0 1 2
Terbutaline-PO 0 1 2
Terbutaline-pump 0 1 2
Terbutaline-SC 0 1 2
Cesarean section 0 1 2
Forceps vaginal delivery 0 1 2
Interventions/Monitor
Patients with Anesthesia
General 0 1 2
Epidural 0 1 2
Local 0 1 2
Spinal 0 1 2
Spontaneous vaginal delivery 0 1 2
Vacuum extraction delivery 0 1 2
PREGNANCY - Interventions/Pain Management
Assessment of pain level/tolerance 0 1 2
Epidural analgesia 0 1 2
IV conscious sedation 0 1 2
INFANT INTERVENTIONS POST DELIVERY -Assessment
Apgar scoring 0 1 2
Initial vital signs 0 1 2
Intervention/risk factors for IDM 0 1 2
Intervention/risk factors for LGA, SGA, IUGR 0 1 2
Newborn Physical Assessment
Ballard 0 1 2
Dubowitz 0 1 2
Finnegan scoring 0 1 2
Suctioning
Bulb 0 1 2
Delee 0 1 2
Wall 0 1 2
Identification
Bands 0 1 2
Footprints 0 1 2
Radiant warmer 0 1 2

Age Specific Practice Criteria
Please check the appropriate boxes below for each group for which you have experience in providing age-appropriate nursing care.
A=Newborn/Infant(0-30 Days) B= School Age(6-12 Yrs) C= Adolescent(13-18 Yrs) D=Young Adult(19-64 Yrs) E=Middle Adult(40-64 Yrs)
A
B
C
D
E
Able to adapt care to incorporate normal growth and development.
Able to adapt method and terminology of patient instructions to their age, comprehension and maturity level.
Able to ensure a safe environment to reflect needs and alter environment accordingly.
Able to administer medications appropriately and understand different meds, dosages, and possible side effects.
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