Mother and Baby – Professional Nursing Service

Email*

Phone*

Years Experience in Clinical Specialty:*

Directions for Completing Skills Checklist

The following is a list of equipment and/or procedures performed in rendering care to patients. Please indicate the level of experience/proficiency with each and, where applicable, the types of equipment and/or systems with which you are familiar.

Use the following KEY as a guideline:
A) Theory Only/No Experience - Didactic instruction only, no hands-on experience.
B) Limited Experience - Knows procedure/has used equipment, but has done so infrequently or not within the last six months.
C) Moderate Experience - Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed.
D) Proficient/Competent - Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach.

General Knowledge

1. Provision of Care:*

	A	B	C	D
Assess pain and alternative non-pharmacologic comfort measures used to assist in alleviation of pain
Provide care to at-risk patients (i.e.: fall precautions, seizure precautions, bleeding precautions, aspiration precautions)
Provide customer service oriented care such as responding to patient and family member questions and needs in a timely manner.
Provide support in family adaptation situations i.e.: adoption, surrogacy, teenage mother
Recognize appropriate interactions between mother and infant to ensure adequate bonding

2. Mechanisms of heat loss:*

3. Assist with common procedures done by a licensed independent practitioner at the bedside:*

4. Equipment:*

	A	B	C	D
Apnea Monitor
Cardiac Monitor
Infant warmers
IV Pumps
Oxygen flow meter
Oxygen tubing
Patient beds
PCA Pumps
Phototherapy
Sequential compression devices
Suction catheters
Suctioning equipment
Urine drainage bags
Vital sign equipment
Wound drainage devices

Maternal Assessment/Management

1. Perform maternal assessment:*

	A	B	C	D
Bowel sounds
Breast Engorgement
Cardiovascular System
DTR
Episiotomy
Fundal Height
Gastrointestinal System
Genitourinary System
Heart sounds
Incision site
Integumentary
Laceration
Location/position of uterus
Lung sounds
Neurological assessment
Parental/infant interaction
Perineum(hematoma/hemorrhoids)
Presence, amount, color and odor of lochia

2. Interpretation of Lab Results:*

3. Provision of care in lactation process:*

4. Perform:*

	A	B	C	D
Adult CPR
Dressing changes
Foley catheter insertion
Nasogastric tube placement
Peri-care
Peripheral IV catheter placement
Straight catheterization
Wound care
Collection and labeling of blood specimen
Collection and labeling of sputum specimenCollection and labeling of stool specimen
Collection and labeling of stool specimen
Collection and labeling of urine specimen
Collection and labeling of wound drainage specimen
Correct sterile technique when performing procedures such as dressing changes
End of life care and post-mortem care for mother/infant
Measurement of intake and output as part of the plan of care

5. Recognize maternal abnormalities:*

	A	B	C	D
Abnormal blood glucose levels
Abnormal intake and output
Abnormal lab values
Abnormal vital signs
Interpretation of normal/abnormal oxygen saturations
Signs/symptoms Amniotic fluid disorders
Signs/symptoms DIC
Signs/symptoms Eclampsia
Signs/symptoms gestational diabetes
Signs/symptoms infectious diseases
Signs/symptoms maternal hemmorhage
Signs/symptoms retained placenta

6. Provision of Care in the GYN patient:*

7. Recognize:*

Newborn Assessment/Management

1. Perform newborn assessment:*

	A	B	C	D
APGAR scores
Ballard Scale
Bowel sounds
Cardiovascular System
Cord gases
DTR
Gastrointestinal System
Genitourinary System
Heart sounds(Apical)
Integumentary
Lung sounds
Motor skills
Neurological assessment
Pain cues
Respiratory effort
Temperature

2. Recognize newborn abnormalities:*

	A	B	C	D
Abnormal blood glucose levels
Abnormal intake and output
Abnormal lab values
Abnormal sleep patterns
Abnormal vital signs
Abnormal weight
Bowel Obstruction
Chorioamnionitis
Chromosomal abnormalities
Cleft palate/lip
Conjuctivitis
Diabetes
Down Syndrome
Epsteins pearls
Erythema toxicum
GBS (Group B Strep)
Genetic disorders
Hydrocephalus
Hyperbilirubinemia
Hypothermia
Interpretation of abnormal oxygen saturations
Meconium aspiration
Mongolian spots
Mother to Infant transmission i.e.:Sexually transmitted infections
Premature infant
Respiratory distress syndrome
Rh disease and ABO compatibility
S/S drug/alcohol withdrawal
Sepsis
Shoulder dystocia
Signs of dehydration
Signs of hypoglycemia
Umbilical Hernia

Mother Baby Pharmacology

1. Administration:*

Professional Practice

1. Serve as patient advocate for both mother and infant:*

	A	B	C	D
Collaborate with social services and other health care professionals in the patient’s plan of care
Communicate findings to appropriate caregiver/providers
Communicate with culturally diverse populations through chaplains
Communicate with culturally diverse populations through interpreters
Communicate with culturally diverse populations through social services
Evaluate outcomes based upon analysis of assessment data
Independently make decisions, problem solve, and use critical thinking in caring for mother and infant
Report relevant information to physician
Implement Conflict resolution techniques used to de-escalate stressful situations

2. Participate in organizational emergency response plans:*

3. Participate:*

4. Legal/Regulatory*

5. Delegation:*

6. Link patients to community resources:*

Mother Baby Education

1. Utilize various modalities for patient/family education:*

2. Provide education:*

	A	B	C	D
Apnea monitoring
Bottle feeding techniques and equipment used
Circumcision
Contraceptive counseling
Cord care
Diarrhea
Elimination patterns in bottle feeding
Fever
Follow up care for newborn with primary health care provider
Hygiene
Infant caretaking skills
Infant CPR
Jaundice
Latch-on techniques
Nipple care
Nutritional needs in bottle feeding
PKU
Positioning
Post Cesarean Care
Required immunizations/schedule
Routine Discharge teaching
Signs of adequate intake
Supplemental feedings
Use of breast pump (manual/electric)
Warning Signs

Age Specific:

Please indicate the frequency with which you provide care for each age group:*

Date*

	A	B	C	D
Circumcision
D&C
Epidural catheter pumps
Epidural catheter removal
IV Conscious Sedation
PICC line placement

	A	B	C	D
Breast engorgement
Feeding cues
Mastitis
Maternal nutritional needs
Nipple problems
Positioning
Proper latch
Suck/swallow sequence

	A	B	C	D
A&P repair
Hysterectomy
Pelvic support procedures
PID

	A	B	C	D
Antibiotics
d-TAP
Erythromycin ointment
Hep B vaccination
Magnesium sulfate
Narcotic analgesics
Oxytocin
Rhogam
Rubella
Vitamin K

	A	B	C	D
Bomb threat
Cardiac arrest
Fire
Infant abduction
Rapid response
Tornado

	A	B	C	D
Understands physiologic mechanisms (i.e.: Conduction, Convection, Evaporation, Insensible water loss, Radiation)
Swaddling techniques
Temperature maintenance i.e.: infant warmers

	A	B	C	D
Chemistry
Coagulation Studies

	A	B	C	D
Signs and symptoms of abuse, neglect in mother/newborn
Signs and symptoms of drug and alcohol dependence/withdrawal in mother/newborn

	A	B	C	D
Completion of incident or variance reports
Data collection in PI process
Events or issues reportable to the state board of nursing such as impairment, diversion, fraud, safe harbor
QA initiatives

Mother and Baby Skills Checklist