L&D / Mother / Baby / Post Partum

Requested by *

Recruiter Email ID *

First Name *

Last Name *

Phone Number *

Today's Date *

Your Email Address *

WORK SETTING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Inpatient Acute Care Facility *

Trauma Center *

Academic/Teaching Facility *

Outpatient Care Facility *

Long term care/Skilled Nursing *

Clinic/Ambulatory *

Home Health Setting *

GENERAL SKILLS EXPERIENCE

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Advanced directives *

Patient / family teaching *

Discharge planning *

Lift / transfer devices *

Specialty beds *

Restrictive devices (restraints) *

End of life care / palliative care *

Wound assessment & care *

Bar coding for medication administration *

Coaching needs: physical / emotional / comfort *

Assist with sterile speculum exam (effacement, dilation, station, presentation) *

Vaginal exam (effacement, dilation, station, presentation) *

Performs sterile speculum exam independently *

Use of doppler *

National Patient Safety Goals *

Accurate patient identification *

Effective communication *

Automated Medication Dispensing System, Pyxis, Omnicell, or other *

Time out protocol *

Interpretation & communication of lab values *

Medication administration *

Labeling (medications & specimens) *

Medication reconciliation *

Anticoagulation therapy *

Monitoring conscious sedation *

Pain assessment & management *

Use of PCA (IV) *

Epidural *

Infection control *

Universal precautions *

Awareness of HCAHPS *

Isolation *

Prevention of pressure ulcers *

Minimize risk for falls *

CARDIAC MONITORING & EMERGENCY CARE

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently *

Preparation & administration of emergency drugs *

Infant / neonatal arrest / NRP *

Adult cardiac arrest / ACLS *

Obtains 12 lead EKG *

Interpretation of rhythm strips *

Use of rapid response teams *

Pulse oximetry *

Interpretation of ABG’s *

O2 (NC / mask / oxyhood) *

Assist with intubation *

Suctioning *

IV THERAPY

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Start & maintain peripheral IV *

Start & maintain scalp veins *

Maintain central lines (CVC / PICC) *

Administration of blood & blood products *

TPN/lipids *

Use of infusion pumps / drips / IV monitoring *

PATIENT MONITORING EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Assist / monitor anesthesia *

General anesthesia *

Regional / spinal / epidural *

CARE OF PATIENT WITH PRE-EXISTING PROBLEMS:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Cardiac disease *

Neurological disease *

Seizure disorder *

Prior tubal ligation *

Diabetes mellitus *

Infectious disease *

Sickle cell disease *

RH incompatibilities *

HIV *

ANTEPARTUM CARE & PROCEDURES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Triage of obstetrical patients *

NST (Non Stress Tests) *

OCT (Oxytocin Challenge Tests) *

Carotid EnReflex checks / edema assessment / clonusdarterectomy *

Assist with amniocentesis *

CARE OF PATIENT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Pregnancy induced hypertension *

Pre-eclampsia / eclampsia *

Preterm labor *

VBAC management / trial of labor *

Placenta previa *

Abruptio placenta *

Uterine rupture *

Multiple gestation *

Malpresentations (breech / face / brow) *

MEDICATION & ADMINISTRATION:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Pitocin (oxytocin) *

Prostaglandins *

Cytotec, misoprostol *

Ritodrine *

Magnesium sulfate therapy *

Corticosteroids *

Insulin drips *

Terbutaline *

LABOR ASSESSMENT & PROCEDURES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Assess & document progression of labor *

Abdominal / perineal prep *

Assist with AROM procedure *

Assess & document fetal status *

Use of EFM (External Fetal Monitor) *

Use of IFM (Internal Fetal Monitor) *

Assist with IUPC placement & calibration *

Amnioinfusion *

Assist with vaginal delivery *

Forceps / vacuum extraction *

Shoulder dystocia *

Emergency delivery *

Hemorrhage / shock *

Assist with high risk delivery *

Circulate for c-section *

Scrub for c-section *

Assist with fetal scalp blood sampling *

Fundal assessment / height *

MEDICATION & ADMINISTRATION:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Pitocin (oxytocin) *

Prostaglandins *

Cytotec, misoprostol *

Ritodrine *

Magnesium sulfate therapy *

Corticosteroids *

Insulin drips *

Terbutaline *

LABOR ASSESSMENT & PROCEDURES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Assess & document progression of labor *

Abdominal / perineal prep *

Assist with AROM procedure *

Assess & document fetal status *

Use of EFM (External Fetal Monitor) *

Assist with IUPC placement & calibration *

Amnioinfusion *

Assist with vaginal delivery *

Forceps / vacuum extraction *

Shoulder dystocia *

Emergency delivery *

Hemorrhage / shock *

Assist with high risk delivery *

Circulate for c-section *

Scrub for c-section *

Assist with fetal scalp blood sampling *

Fundal assessment / height *

IMMEDIATE CARE OF BABY IN DELIVERY ROOM EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Newborn assessment / apgar scores *

Routine neonatal medications *

Meconium *

Eye prophylaxis *

Collect cord sample *

Heelsticks *

Radiant warmer / thermoregulation *

Elderly (ages 80+ years) *

POSTPARTUM CARE EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Fundus / lochia / perineum care *

Episiotomy / incision care *

Postop c-section *

Bladder assessment *

Foley catheter insertion *

Breast feeding instructions *

Couplet care *

Baby friendly protocols *

NEWBORN CARE GENERAL SKILLS EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Neonatal level II/III (complete NNICU checklist) *

Newborn nursery *

Full body assessment *

ASSIST WITH INSERTION OF & MAINTENANCE OF:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

UAC/UVC *

Swanz Ganz *

High Frequency Jet Ventilation (HFJV) *

Obtain specimens from UAC/UVC *

Extra Corporeal Membrane Oxygenation (ECMO) *

Radiant warmers *

Apnea monitoring *

Glascow coma scale *

Assist with lumbar puncture *

Calculation of pedi dosage *

Phototherapy *

Cord & circumcision care *

CARE OF THE INFANT WITH:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Bowel obstruction *

Broncho-pulmonary dysplasia *

Drug addiction / withdrawal *

CHF (Congestive Heart Failure) *

Cystic fibrosis *

Intracranial hemorrhage *

HIV *

Diabetes mellitus *

Low birth weight infants *

NEC (Necrotizing Enterocolitis) *

Neuromuscular disease *

PDA (Patent Ductus Arteriosus) ligation *

Pneumonia *

RDS (Respiratory Distress Syndrome) *

Sickle cell disease *

Seizure activity *

Pulmonary edema *

Spina bifida *

Systemic infection *

Tetralogy of Fallot *

Tracheoesophageal fistula *

Transposition of great vessels *

AGE-SPECIFIC COMPETENCIES EXPERIENCE:

Rank each of the following sections on a scale of 1 to 3:

Limited or no experience
Experienced, but may need review or supervision
Able to function independently

Newborn / neonate (birth-30 days) *

Infant (31 days-1 year) *

Toddler (ages 2-3 years) *

Preschool (ages 4-5 years) *

School age (ages 6-12 years) *

Young adult (ages 22-39 years) *

Adult (ages 40-64 years) *

Older adult (ages 65-79 years) *

Elderly (ages 80+ years) *

Adolescent (ages 13-21 years) *