Instructions:

Please rate your experience / frequency (within the last year) using the following scale (check the appropriate boxes below):

  • 0 = No Experience / Observed Only
  • 1 = Limited Experience / Rarely Done (<6 times/year)
  • 2 = May Need Some Review / Occasionally Done (1 - 2 times/month)
  • 3 = Experienced / Frequently Done (daily or weekly)
    		•
    AGE OF PATIENTS CARED FOR
    Newborn/Neonate (birth to 30 days)
    Infant (31 days to 12 months)
    Toddler/Preschool (13 months to 5 years)
    School Age Child/adolescent (6 years to 18 years)
    Young Adults/Middle Adult (19 years to 64 years)
    Older Adults/Elderly (65+ years)
    GENERAL SKILLS
    Automated Med Dispensing Systems
    Electronic Documentation
    Peripheral IV Insertion, Care and Maintenance
    Access/Management of Implanted Ports
    Access/Management of Central Lines (CVL, Hickman, Broviac, Groshong, etc.)
    End of Life Care
    Care of Patient in Restraints
    Patient and Family Teaching
    Knowledge of "Do Not Use Abbreviations"
    Coaching Needs: Physical and Emotional
    Adult Cardiac/Respiratory Arrest
    Infant/Neonatal Cardiac/Respiratory Arrest
    Administration of Blood/Blood Products
    Knowledge of Normal Lab Values(Newborn)
    Knowledge of Normal Lab Values(Labor Patient)
    Do you have charge/supervisor experience?
    Knowledge of current Joint Commission National Patient Safety Goals
    Knowledge/familiarity with HCAHPS scores
    Other Automated Med Dispensing Systems:
    Other Electronic Documentation:
    IV Pumps
    Other IV Pumps:
    CARE OF THE PATIENT W/ PRE-EXISTING CONDITIONS/HIGH RISK OB
    Cardiomyopathies
    Tachysystole
    Neurological Disease
    Gestational Diabetes Mellitus
    Asthma
    Chronic Hypertension
    Gestational Hypertension
    Cholestasis of Pregnancy
    Infectious Disease
    STIs
    Hepatitis B
    HIV
    Sickle Cell Disease
    Rh Incompatibilities
    Hemolytic Anemia
    Collagen Vascular Disease
    Hemorrhage
    Drug Addiction/Withdrawal
    Pyelonephritis
    Prolapsed cord
    Abruptio Placenta
    Placenta Previa
    Placenta Acreta
    Preeclampsia
    Eclampsia
    HELLP Syndrome
    DIC
    Premature Labor
    Malpresentations
    Breech Presentation
    Transverse Lie/Shoulder
    Face Presentation
    Brow Presentation
    Multiple Gestation
    Premature Rupture of Membranes
    Chorioamnionitis
    Poly/Oligohydramnios
    Prior Tubal Ligation
    VBAC Management/TOLAC
    Uterine Rupture
    Incompetent Cervix (Shirodkar Suture/Cerclage)
    Spontaneous Abortions - Complete/Incomplete
    Intrauterine Growth Restriction (IUGR)
    Postdate Pregnancy
    Fetal Demise
    ANTEPARTUM:
    Triage of Obstetrical Patients
    Assessment of Birth Plan
    Perform Admission Risk Assessment
    Non-Stress Test (NST)
    Induction of Labor
    Oxytocin Challenge Tests (OCT)
    Assist with Amniocentesis
    Deep Tendon Reflex Checks (DTR's)
    Edema Assessment
    Clonus
    Breathing/Relaxation Techniques
    Knowledge and Adminsitration of
    Narcotic Analgesics (nalpuphine HCL, morphine sulfate, hydromorphone HCL, oxycodone)
    Oxytocics (oxytocin, methylergonovine, carboprost, prostaglandin)
    Magnesium Sulfate
    Terbutaline
    Betamethasone steroids
    Indomethacin
    Antifibrinolytics (tranexamic acid, amnioaproic acid, aprotinin)
    Pitocin
    Cervidil
    Cytotec
    Prostin Suppositories
    Assist with Prostin Gel
    Fibrinolytics (reteplase, streptokinase, t-PA, anistreplase)
    Mucolytics (acetylcysteine, ambroxol, bromhexine, carbocisteine)
    H2 Blockers (famotidine, ranitidine, cimetidine, nizatidine)
    Proton pump inhibitors (omeprazole. lansoprazole, pantoprazole)
    Antihistamines (diphenhyramine, clemastine, loratidine, cetirizein)
    Antibiotics (pentacillin, doxycycline, cephalexin, cirpofloxin, metronidazole, levofloxacin)
    Antifungals (miconazole, Fluconazole, clotrimazole, econazole, amphotericin)
    IV Labetalol
    IV Hydralazine
    Procardia
    PO Labetalol
    Anticoagulants (heparin, warfarin, rivaroxaban, enoxaprin, apixaban)
    Antidiabetics (metformin, glipizide, glyburide, glimepiride)
    Insulin Drips
    Insulin Pumps
    Insulin SC (rapid acting, short acting, imtermediate acting, long acting, pre-mixed)
    Antiviral Medications (Acyclovir, AZT)
    Rhogam
    Antipsychotics (risperidone, clozapine, quetiapine, aripiprazole)
    Antidepressants (Paroxetine, fluoxetine, sertraline, citalopram)
    Benzodiazepines (clonazepam, alprazolam, diazepam, lorazepam)
    IV THERAPY/PROCEDURES
    Invasive Hemodynamic Monitoring
    Blood/Fluid Warmers
    Mass Transfusion Protocol (MTP)
    LABOR ASSESSMENT/PROCEDURES (MATERNAL):
    Stages and Phases of Labor and signs and symptoms of progress
    Assist with Sterile Speculum Exam
    Perform Sterile Speculum Exam
    Vaginal Exam - Manual
    Status of Membranes
    Assist with Rupture of Membranes
    Fern Test
    Nitrazine
    Presence of Clonus
    DTR's
    Edema
    Progression of Labor
    Assess Station/Dilation/Effacement
    Determine Fetal Position/Presentation
    Contraction Characteristics
    Determination of Fetal Head Position
    Documentation of Labor Status and Interventions
    Labor Suppressants
    Procedures
    Collect and label vaginal cultures
    Perform Leopold's Maneuvers
    Amnioinfusion (assist or perform) for variable decelerations
    Amniofusion (assist or perform) for meconium
    Amniofusion (assit or perform) for prolapsed cord
    Amniofusion (assist or perform) for vasa previa
    Catheter Insertion
    LABOR ASSESSMENT/PROCEDURES (Fetal):
    Fetal Heart Rate - Doppler
    Fetal Heart Rate - Auscultate
    Fetal Heart Rate Patterns (Identify & Treat):
    Variability
    Variable Decelerations
    Early Decelerations
    Late Decelerations
    Prolonged Decelerations
    External Fetal Monitor Application
    Internal Fetal Monitor Application (Assist)
    Internal Fetal Monitor Application (Perform)
    Spiral Electrode
    Intrauterine Pressure Catheter (IUPC) placement and calibration
    DELIVERY
    Assist with Vaginal Delivery
    Forceps Extraction
    Vacuum Extraction
    Assist with High Risk Delivery
    Shoulder Dystocia
    Hemorrhage/Shock
    Quantitative Blood Loss Assessment
    Uterine Balloon Tamponade
    Pulmonary Embolism
    Amniotic Embolism
    Emergency Delivery
    Perineal Prep
    Circulate for C-Section
    Scrub for C-Section
    Patient with General Anesthesia
    Patient with Epidural Anesthesia
    Circulate for Tubal Ligation
    Scrub for Tubal Ligation
    Assist with Placenta Delivery
    Assist with Cervical Laceration Repair
    Assist with Uterine Laceration Repair
    Assist with Episiotomy Repair
    IMMEDIATE CARE OF NEWBORN IN DELIVERY ROOM
    Newborn Assessment
    Ballard
    Dubowitz
    Finnegan/Abstinence Scoring
    Apgar Scores
    Initial Care
    Bulb Suction
    Wall Suction
    Meconium Aspiration
    Collect Cord Samples
    Placental Stem Cell Collection
    Assist with UAC/UVC Insertion
    Insertion of IV, Including Scalp IV
    Radiant Warmer/Thermoregulation
    Interventions for LGA, SGA, IUGR
    Interventions for Infant of Diabetic Mother
    Oxygen Administration
    Bag/Mask Ventilation of the Newborn
    Assist with Intubation
    Transport Isolette
    Heelstick Glucose
    POSTPARTUM CARE
    Fundal Height and tone
    Fundal Massage
    Lochia Assessment
    Episiotomy Care
    Maternal Vital Signs
    Recovering Post-Op C-Section Patient
    Recovering Post-Op Tubal Ligation Patient
    Fluid Balance
    Assessment for DVT
    Couplet Care
    NEWBORN CARE
    Assessing transition from inuterine to extrauterine life
    Idenitfying signs and symptoms of respiratory distress such as grunting, flaring, and retractions
    Swaddling
    Monitoring I's and O's
    Assessing suck for coordination
    Soothing techniques
    CARE OF THE INFANT WITH
    Assist with Lumbar Puncture
    Administration of IV Antibiotics
    Drug Addiction/Withdrawal
    Cystic Fibrosis
    Meconium Aspiration
    Pulmonary Edema
    Respiratory Distress Syndrome
    Necrotizing Enterocolitis
    Cardiac Anomalies
    Neuromuscular Disease
    Spina Bifida
    Seizure Activity
    Tracheoesophageal Fistula
    Sepsis
    Sickle Cell Disease
    Cephalohematoma
    Jaundice
    Broken clavicle
    Cleft lip/cleft palate
    Car Seat Tolerance Test
    Low Birth Weight Infants
    PAIN MANAGEMENT/ANESTHESIA
    Assess Pain Level/Acceptable Level of Pain
    Non-pharmalogical Pain Management
    Intranasal Pain Medications
    Oral Pain Medications
    IV Pain Medications
    Patient Controlled Analgesia
    IV Moderate/Conscious Sedation
    Epidural Pain Management
    Intervention for Anesthesia Toxicity
    Assist with Epidural Insertion
    Positioning of Patient
    Signs of a Dural Puncture
    Coaching Patient
    Fluid Challenge
    Hypotension
    Intrathecal Narcotics
    MY EXPERIENCE
    Fetal Monitoring Course - Basic
    Fetal Monitoring Course - Intermediate
    Fetal Monitoring Course - Advanced
    Number of Deliveries per Month (average in last year):
    Have you ever experienced an unattended delivery?:
    Breastfeeding
    Hand expression
    Football hold
    Cradle and cross cradle
    Skin to skin
    Signs of nutritive swallowing