Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
LABOR AND DELIVERY
Monitor IV drips 0 1 2
Oxytocin 0 1 2
Magnesium Sulfate 0 1 2
Other anticonvulsants for pre-eclampsia 0 1 2
Labor suppressants (e.g. Rigodrine) 0 1 2
Set up a cesarean section 0 1 2
Circulate for a cesarean section 0 1 2
Scrub for a ceasarean 0 1 2
Set up a delivery table 0 1 2
Assist with fetal scalp blood sampling procedure 0 1 2
Assess contraction characteristics 0 1 2
Conduct a stress test (oxytocin challenge test) 0 1 2
Conduct non-stress test 0 1 2
Assessment and document progression of labor 0 1 2
Status of membranes 0 1 2
Assess and document fetal status 0 1 2
Ausculate FHR (fetal heart rate) with fetoscope 0 1 2
Guide labor coach 0 1 2
Do perineal prep 0 1 2
Using birthing chair/bed 0 1 2
Assist with spontaneous vaginal delivery 0 1 2
Assist with forceps vaginal delivery 0 1 2
Assess parent/infant bonding 0 1 2
MONITOR UTERINE ACTIVITY & FHR PATTERNS
USING
External monitor:
Fetal ECG transducer 0 1 2
Ultrasound/phono 0 1 2
Internal monitor:
Locotransducer 0 1 2
Intrauterine pressure catheter 0 1 2
Identify FHR pattern size: 0 1 2
Variability/Reactivity
Identify FHR pattern size:
Decelerations-early, late 0 1 2
Identify FHR pattern size:
Tachycardia/Bradycardia 0 1 2
Pregnancy induced hypertension 0 1 2
RH imcompatibilities 0 1 2
Chemical dependency 0 1 2
Hemorrhage 0 1 2
Preeclampsia 0 1 2
Eclampsia 0 1 2
Placenta previa 0 1 2
Abruptio placenta 0 1 2
Multiple gestation 0 1 2
Malpresentations 0 1 2
Premature labor 0 1 2
Diabetes mellitus 0 1 2
Do a perineal prep 0 1 2
IMMEDIATE CARE OF INFANT POST BIRTH
Assign apgar scores 0 1 2
Dubowitz assessment of gestational age 0 1 2
PHYSICALLY EXAMINE NEWBORN FOR
Anomalies 0 1 2
Respiratory status 0 1 2
MISCELLANEOUS INFANT CARE
Bulb Suction 0 1 2
Delee Suction 0 1 2
Wall Suction 0 1 2
Chest percussion 0 1 2
Weigh infant 0 1 2
Identify infant using bracelet, footprints 0 1 2
Eye Prophylaxis 0 1 2
Collect cord blood samples 0 1 2
Dextrostix 0 1 2
Hematocrit 0 1 2
POSTPARTUM ASSESSMENT
Fundus Consistency 0 1 2
Lochia 0 1 2
Bladder distention 0 1 2
Episiotomy care 0 1 2
Abdominal distention 0 1 2
POST ANESTHESIA RECOVERY PRECAUTIONS
Spinal 0 1 2
Epidural 0 1 2
General 0 1 2
Initiate fundal massage 0 1 2
Provide perineal care 0 1 2
Assisting with sitz bath 0 1 2
Assisting with breast pump 0 1 2
Postpartum teaching 0 1 2
Breast feeding 0 1 2
Self-care at home 0 1 2
Care of the newborn 0 1 2
Assessment of teaching needs 0 1 2
Circulate for postpartum tubal ligation 0 1 2
Scrub for postpartum tubal ligation 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 (0-30 days) B=School Age (6-12 yrs) C=Adolescent (13-18 yrs) D=Young Adult (19-39 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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