Labor & Delivery Nursing Assessment Checklist
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1 Labor & Delivery Nursing Assessment Checklist NAME: DATE LEVEL OF COMPETENCE 1. No experience Never or observed only 3. Performs Independently Consistently practices 2. Needs Assistance Occasionally practices 4. Serves as Resource/Preceptor - frequently practices LABOR AND DELIVERY SKILLS I. MEDICATION ADMINISTRATION Cesarean Prep Perineal Prep Knowledge of Administration Protocol & Side Effects of: Analgestics Antibiotics Anticonvulsants Calcium Gluconate Corticosteriods During Hemabate Heparin Hydralazine Insulin Magnesium Sulfate Methergine Narcotics Oxytocin Ritodrine Terbutaline Calcuim Chloride II. GENERAL OBSTETRICAL MANAGEMENT Assessment of Labor: Assess for Risk Factors Cervical Dilation and Changes Cervical Effacement and Changes Duration of Contractions Frequency of Contractions Identity of Fetal Part Obtain OB History Psychological/Behavioral Status of Patient Quality of Contractions Station of Presenting Part Assist with: Amnioinfusion Collection of Cultures Epidural Catheter Placement Prepare Patient Physically for Labor Prepare Patient Psychologically for Labor Provide Care & Monitor After Rupture of Membrane Support Labor Coach as needed DELIVERY INTERVENTIONS Assist Physician with Anesthesia during Delivery Circulate for: Cesarean Section Circulate for: Minor Surgical Procedure. Circulate for: Postpartum Tubal Ligation Circulate for: Vacuum Extraction Circulate for: Vaginal Delivery Documents Delivery On Patient Chart & Logbook Initiate Emergency Protocols if needed Knowledgeable of AWHONN Standard of Practice Performs Controlled Emergency Delivery in absence of doctor Scrubs for: Cesarean Section Minor Surgical Procedure Postpartum Tubal Ligation Vacuum Extraction Vaginal Delivery Sterile Set Up: Birthing Room Cesarean Delivery Delivery Room Forceps / Vacuum Vaginal Delivery Spontaneous Vaginal Delivery Assist Physician with Anesthesia during delivery CARE OF INFANT Assess and Assign Apgar Score Cord Blood Samples Labor & Delivery Nursing Assessment Checklist Page 1 of 5
2 III. LABOR MANAGEMENT INTERPARTUM ASSESSMENT Assess Maternal vs. Per Stage of Labor Assist with Insertion of IUPC Assist with placement of FSE Correctly Interpret & Document Fetal Status: Apply Tocotransducer and Ultrasonic FHM Identify Indicators of Fetal Distress Initiate Emergency Measures for Fetal Distress Report Fetal Distress to Physician Interpret Data: Fetal Heart Pattern Uterine Contraction Pattern Knowledgeable of Calibration of Machine Knowledgeable of Lead Connections Use of Doptone (US Doppler) Use of Fetoscope Use of Radiant Monitor INTRAPARTUM INTERVENTIONS Assist with Amniotomy Care of Patient for Anesthesia Administration: Assist Physician with Induction Documentation General Positioning Protocol for Consent Chest Percussion Dextrostix Establish and Maintain Patent Airway Eye Care Hematocrit Identification Process Bracelet / footprints Initiate Emergency Measures Knowledgeable of S/S Infant Distress Physical Exam of Newborn: Assess for Anomalies Respiratory Status Prevention of Heat Loss Promote Bonding Process Suction: Bulb Wall Transfer to Nursery Weight POSTPARTUM RECOVERY PERIOD Accurate Assessment and Documentation of: Amount and Character of Lochia Bladder Status Fundal Consistency and Height Incision Cesarean Regional: Epidural Episiotomy Local Infiltration Spinal Coach with Breathing and Relaxing Techniques Conduct Vaginal Exam IV. CARE OF PATIENT WITH: Abrupto Placenta Asthma Cardiac Disease Cystitis Diabetes Mellitus Drug Abuse Eclampsia Hemorrhage Hypotension from Regional Anesthesia Infectious Disease Malpresentation Post-Anesthesia Assessment Score Provide Period of Bonding Psychological Status Report Condition to Postpartum Unit II. MEDICATION Depo Provera Ergotamine Preparation Hormone Preparations MagSo4 Methergine Oxytocin-Pitocin Drip Parlodel RHoGam Preparation Labor & Delivery Nursing Assessment Checklist Page 2 of 5
3 Multiple Gestation Rubella Vaccine Neuromuscular Disease Suppositories Paralysis Trace Placenta Previa Vaginal Creams Pre-Eclampsia Pregnancy-Induced Hypertension III. BIRTH CERTIFICATION Premature Labor Complete a Birth Certificate and Record Prolapsed cord Pyelonephristis IV. POST-BIRTH CARE Respiratory Arrest C-Section Rh Incompatibilities Abdominal Dressing Ruptured Uterus Incentive Spirometry Sickle Cell Disease Pain Relief Seizures Preeclampsia Transverse vs. Classic Incision V. OBSTETRICAL PROCEDURES Epidural Anesthesia Adoption Protocol Natural Childbirth Aseptic Technique for Delivery Room Spinal Anesthesia Aseptic Technique for Labor Room Activity CPR: Diet Adult Elimination Infant Fundus Assist with Intubation Lochia Assist with Umbilical Artery V. MATERNAL CARE HOME INSTUCTIONS Catheter Insertion Activity Level C-PAP Bag Breast Care Chest Compressions Emotional Adjustments Emergency Medications Follow-Up with Physician Documentation for Hospital/State Protocols Medications Fetal Demise Ovulation and Menstruation Induction of Labor: Comfort Measures Recognizing Signs of Infections Medication Protocol Provide Psychological Support NEWBORN NURSERY Signs and Symptoms of Complications I. ADMISSION FROM: Intake and Output C-Section Specimen Collection Delivery Room Vaginal Birth Stress Test Oxytocin Challenge Test: Outside Delivery Area Contraction Stress Test Non-Stress Test II.DAILY CARE Surrogate Mother Protocol Circumcision Care Cord Care POSTPARTUM SKILLS Feeding I. MONITOR / INSTRUCT PATIENT ON: Bottle Bladder Care Breast Labor & Delivery Nursing Assessment Checklist Page 3 of 5
4 Distension Empty Bladder Intervention if Unable to Void Bowel Care: Hemorrhoids Incision Care Breast Care Bottle Feeding Breast Feeding Breast Pump Breast Engorgement Episiotomy Care Heat Lamp Peri-Care Sitz Bath Tubal Ligation Ultrasound Nasogastric Suctioning Bulb Phototherapy Lights Postural Drainage and PT Gastric IV. MEDICATION ADMINISTRATION Antibiotic Erythromycin Ointment Silver Nitrate Vitamin K Preparation Hepatitis Vaccination V. USE AND MAINTAIN THE FOLLOWING EQUIPMENT Automatic B/P Machine Breast Pump Cardio-Respirator Monitor Infant Scales Isolette Radiant Warmer NG Skin Care Infant Bath Infant Elimination Infant Follow-up Infant Sleep Patterns Need of PKU Testing Recognize Signs of Infections III. DEMONSTRATE PROPER TECHNIQUE FOR THE FOLLOWING PROCEDURES Assisting with Circumcisions Exchange Transfusion Gastric Lavage NG Tube Insertion NT Suction VI. SPECIMEN COLLECTION Cultures Blood Skin Cord Heel Stick Stool Urine Labor & Delivery Nursing Assessment Checklist Page 4 of 5
5 ELECTRONIC FETAL MONITORING COMPETENCY VALIDATION NURSING PRACTICE COMPETENCIES Explains the use of electronic fetal monitor to the patient and her support person(s) 2. Chooses the appropriate electronic fetal monitoring method based on hospital policy or procedure 3. Applies external transducers and adjusts the electronic fetal monitor accordingly 4. Describes the limitations of information produced by external transducers 5. Prepares the patient, sets up equipment, and completes connections for fetal electrode and intrauterine pressure catheter 6. Calibrates the monitor for the use of the intrauterine pressure catheter 7. Identifies artifacts and technically inadequate tracings and takes appropriate corrective action 8. Obtains and maintains an adequate fetal heart rate and uterine contraction tracing 9. Interprets uterine contraction frequency, duration, strength, and baseline resting tone as appropriate based on monitoring method, and determines if abnormal findings are present. 10. Identifies baseline fetal heart rate, baseline variability, and the presence of periodic changes and determines if findings are reassuring or non-reassuring 11. Implements appropriate nursing intervention based on electronic fetal monitor findings. 12. Identifies the clinical situations based on electronic fetal monitor findings in which immediate physician notification is appropriate 13. Communicates the content of electronic fetal monitoring data, its interpretation, and resulting nursing intervention in written and verbal form in an appropriate and timely manner. 14. Documents appropriate entries on the electronic fetal monitoring strip chart and patient record 15. Demonstrates appropriate maintenance of electronic fetal monitoring equipment YOUR EXPERIENCE YOUR EXPERIENCE How many years have you worked in Labor & Delivery How many years have you worked in Newborn Nursery How many years have you worked in Postpartum Labor & Delivery Nursing Assessment Checklist Page 5 of 5
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