Name (First)
(Last)
Years experience in this specialty
0=No Experience    1= Limited Experience    2=Experienced
POSTPARTUM / IV THERAPY
Start peripheral IV 0 1 2
Mixing IVs 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 Product
RBC 0 1 2
Platelets 0 1 2
FFP 0 1 2
Albumin/plasma 0 1 2
Whole blood 0 1 2
Assessment
Bladder distention 0 1 2
Breast engorgement 0 1 2
DVT 0 1 2
Episiotomy 0 1 2
Fundal height 0 1 2
GI function post anesthesia 0 1 2
Lochia amount/color 0 1 2
Vital signs 0 1 2
Parent/infant interaction 0 1 2
Parent/infant attachment 0 1 2
Assessment - Perineum
Hematoma 0 1 2
Hemorrhoids 0 1 2
Interpretation of Lab Results
Glucose 0 1 2
Ketones 0 1 2
Protein 0 1 2
Specific gravity 0 1 2
POSTPARTUM - Patient Care
Asthma 0 1 2
Cardiac disease 0 1 2
Diabetes 0 1 2
Infectious disease 0 1 2
Known substance abuse 0 1 2
Multiple births 0 1 2
Pregnancy induced hypertension 0 1 2
Pregnancy induced preeclampsia 0 1 2
Spontaneous vaginal delivery 0 1 2
Scrub tubal ligation 0 1 2
Circulate tubal ligation 0 1 2
Patient Care - Post Anesthesia
Epidural 0 1 2
General 0 1 2
Local 0 1 2
Spinal 0 1 2
Post-op C-section 0 1 2
Tubal ligation 0 1 2
Insert foley catheter 0 1 2
CPR 0 1 2
Teaching & Assist
Formula preparation & feeding 0 1 2
Teaching & Assist - Breastfeeding
Latch-on procedure 0 1 2
Positioning 0 1 2
Use of electric breast pump 0 1 2
Use of manual breast pump 0 1 2
Infant care taking skills 0 1 2
Perineal care 0 1 2
Sitz bath 0 1 2
Discharge teaching 0 1 2
Contraceptive counseling 0 1 2
Pain Management
Assessment of pain level/tolerance 0 1 2
Epidural analgesia 0 1 2
IV conscious sedation 0 1 2
NEWBORN
Assessment
Ballard scale 0 1 2
Circumference 0 1 2
Dubowitz scale 0 1 2
Length 0 1 2
Neonatal jaundice 0 1 2
Reflexes 0 1 2
Vital signs 0 1 2
Weight 0 1 2
Procedures
Administer injections 0 1 2
APGAR scoring 0 1 2
Bathe infant 0 1 2
Collect cord samples 0 1 2
Cord care 0 1 2
Procedures - Circumcision
Assess post-op 0 1 2
Teach circumcision care to parents 0 1 2
Culture suspected infections 0 1 2
Eye prophylaxis 0 1 2
Incubator/isolette 0 1 2
Infant identification 0 1 2
NEWBORN - Procedures -Monitor Bladder & Bowel
Obtain urine specimens 0 1 2
Test stool for blood 0 1 2
Phototherapy 0 1 2
Radiant warmers 0 1 2
Thermo-neutral environment to prevent
cold stress 0 1 2
Drug addiction/withdrawal 0 1 2
Meconium aspiration 0 1 2
Neonate CPR 0 1 2
Discharge procedure 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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