Labor & Delivery RN Skills Assessment

Labor & Delivery Skills Assessment

Congrats on taking the necessary step to applying for a travel nursing position with us! Before we can offer you an amazing nursing assignment, the following skills assessment must be completed. Take your time and review your information before submitting. We look forward to seeing your results!

Instructions:

This checklist is for assessing your experience in specific clinical areas. It will not be a determining factor in accepting your application to become an employee of Trusted Nurse Staffing LLC.

Please rate your experience using the following scale (check the appropriate boxes below):

0 = No Experience / Observed Only
1 = Less than 1 year experience
2 = 1 - 2 years of experience
3 = Over 2 years of experience

Your Information: *This question is required.

Today's Date: This question requires a valid date format of MM/DD/YYYY.

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First Name

Last Name

Email Address

Phone Number

MEDS/IV THERAPY *This question is required.

Space Cell	0	1	2	3
Administer PO Medications	Administer PO Medications: 0	Administer PO Medications: 1	Administer PO Medications: 2	Administer PO Medications: 3
Administer IM & SQ Meds	Administer IM & SQ Meds: 0	Administer IM & SQ Meds: 1	Administer IM & SQ Meds: 2	Administer IM & SQ Meds: 3
Peripheral IV Insertion	Peripheral IV Insertion: 0	Peripheral IV Insertion: 1	Peripheral IV Insertion: 2	Peripheral IV Insertion: 3
Administer IV Medications	Administer IV Medications: 0	Administer IV Medications: 1	Administer IV Medications: 2	Administer IV Medications: 3
Mix IV Infusion w/ Additives	Mix IV Infusion w/ Additives: 0	Mix IV Infusion w/ Additives: 1	Mix IV Infusion w/ Additives: 2	Mix IV Infusion w/ Additives: 3
Use of Heparin/Saline Locks	Use of Heparin/Saline Locks: 0	Use of Heparin/Saline Locks: 1	Use of Heparin/Saline Locks: 2	Use of Heparin/Saline Locks: 3
Needle-less Systems	Needle-less Systems: 0	Needle-less Systems: 1	Needle-less Systems: 2	Needle-less Systems: 3
Administer/Monitor Oxytocin induction/augmentation	Administer/Monitor Oxytocin induction/augmentation: 0	Administer/Monitor Oxytocin induction/augmentation: 1	Administer/Monitor Oxytocin induction/augmentation: 2	Administer/Monitor Oxytocin induction/augmentation: 3
Administer/Monitor Magnesium Sulfate Therapy	Administer/Monitor Magnesium Sulfate Therapy: 0	Administer/Monitor Magnesium Sulfate Therapy: 1	Administer/Monitor Magnesium Sulfate Therapy: 2	Administer/Monitor Magnesium Sulfate Therapy: 3
Administer/Monitor Magnesium Sulfate Therapy Labor Suppressants -Ritordine	Administer/Monitor Magnesium Sulfate Therapy Labor Suppressants -Ritordine: 0	Administer/Monitor Magnesium Sulfate Therapy Labor Suppressants -Ritordine: 1	Administer/Monitor Magnesium Sulfate Therapy Labor Suppressants -Ritordine: 2	Administer/Monitor Magnesium Sulfate Therapy Labor Suppressants -Ritordine: 3
Administer/Monitor Magnesium Sulfate Therapy Antibiotics	Administer/Monitor Magnesium Sulfate Therapy Antibiotics: 0	Administer/Monitor Magnesium Sulfate Therapy Antibiotics: 1	Administer/Monitor Magnesium Sulfate Therapy Antibiotics: 2	Administer/Monitor Magnesium Sulfate Therapy Antibiotics: 3
Administer/Monitor Magnesium Sulfate Therapy Heparin	Administer/Monitor Magnesium Sulfate Therapy Heparin: 0	Administer/Monitor Magnesium Sulfate Therapy Heparin: 1	Administer/Monitor Magnesium Sulfate Therapy Heparin: 2	Administer/Monitor Magnesium Sulfate Therapy Heparin: 3
Discontinue Peripheral IVs	Discontinue Peripheral IVs: 0	Discontinue Peripheral IVs: 1	Discontinue Peripheral IVs: 2	Discontinue Peripheral IVs: 3
Administer Blood/Blood Products	Administer Blood/Blood Products: 0	Administer Blood/Blood Products: 1	Administer Blood/Blood Products: 2	Administer Blood/Blood Products: 3
Draw Blood for Lab Studies	Draw Blood for Lab Studies: 0	Draw Blood for Lab Studies: 1	Draw Blood for Lab Studies: 2	Draw Blood for Lab Studies: 3
Vital Sign Monitoring	Vital Sign Monitoring: 0	Vital Sign Monitoring: 1	Vital Sign Monitoring: 2	Vital Sign Monitoring: 3
Pulse Oximetry Setup	Pulse Oximetry Setup: 0	Pulse Oximetry Setup: 1	Pulse Oximetry Setup: 2	Pulse Oximetry Setup: 3
Pulse Oximetry Monitoring	Pulse Oximetry Monitoring: 0	Pulse Oximetry Monitoring: 1	Pulse Oximetry Monitoring: 2	Pulse Oximetry Monitoring: 3

INTRAPARTUM PHASE *This question is required.

Space Cell	0	1	2	3
Contraction Characteristics	Contraction Characteristics: 0	Contraction Characteristics: 1	Contraction Characteristics: 2	Contraction Characteristics: 3
Determine Fetal Position	Determine Fetal Position: 0	Determine Fetal Position: 1	Determine Fetal Position: 2	Determine Fetal Position: 3
Status of Membranes	Status of Membranes: 0	Status of Membranes: 1	Status of Membranes: 2	Status of Membranes: 3
Fetoscope	Fetoscope: 0	Fetoscope: 1	Fetoscope: 2	Fetoscope: 3
Doppler Ultrasound	Doppler Ultrasound: 0	Doppler Ultrasound: 1	Doppler Ultrasound: 2	Doppler Ultrasound: 3
External Monitor: Tocotransducer	External Monitor: Tocotransducer: 0	External Monitor: Tocotransducer: 1	External Monitor: Tocotransducer: 2	External Monitor: Tocotransducer: 3
External Monitor: Ultrasound	External Monitor: Ultrasound: 0	External Monitor: Ultrasound: 1	External Monitor: Ultrasound: 2	External Monitor: Ultrasound: 3
External Monitor: Phono	External Monitor: Phono: 0	External Monitor: Phono: 1	External Monitor: Phono: 2	External Monitor: Phono: 3
External Monitor: Abdominal ECG Transducer	External Monitor: Abdominal ECG Transducer: 0	External Monitor: Abdominal ECG Transducer: 1	External Monitor: Abdominal ECG Transducer: 2	External Monitor: Abdominal ECG Transducer: 3
Internal Monitor	Internal Monitor: 0	Internal Monitor: 1	Internal Monitor: 2	Internal Monitor: 3
Variability/Reactivity	Variability/Reactivity: 0	Variability/Reactivity: 1	Variability/Reactivity: 2	Variability/Reactivity: 3
Decelerations-Early,Late,Variable	Decelerations-Early,Late,Variable: 0	Decelerations-Early,Late,Variable: 1	Decelerations-Early,Late,Variable: 2	Decelerations-Early,Late,Variable: 3
Pelvimetry	Pelvimetry: 0	Pelvimetry: 1	Pelvimetry: 2	Pelvimetry: 3
Assessment for Deep Reflexes	Assessment for Deep Reflexes: 0	Assessment for Deep Reflexes: 1	Assessment for Deep Reflexes: 2	Assessment for Deep Reflexes: 3
Assessment for Clonus	Assessment for Clonus: 0	Assessment for Clonus: 1	Assessment for Clonus: 2	Assessment for Clonus: 3
Intake and Output	Intake and Output: 0	Intake and Output: 1	Intake and Output: 2	Intake and Output: 3
Assessment for Edema	Assessment for Edema: 0	Assessment for Edema: 1	Assessment for Edema: 2	Assessment for Edema: 3
Insert Straight/Foley Catheter	Insert Straight/Foley Catheter: 0	Insert Straight/Foley Catheter: 1	Insert Straight/Foley Catheter: 2	Insert Straight/Foley Catheter: 3
Bedside Clinical Testing: Urine Dipstick	Bedside Clinical Testing: Urine Dipstick: 0	Bedside Clinical Testing: Urine Dipstick: 1	Bedside Clinical Testing: Urine Dipstick: 2	Bedside Clinical Testing: Urine Dipstick: 3
Blood Glucose Monitoring	Blood Glucose Monitoring: 0	Blood Glucose Monitoring: 1	Blood Glucose Monitoring: 2	Blood Glucose Monitoring: 3

ASEPTIC TECHNIQUE RELATIVE TO L&D *This question is required.

Space Cell	0	1	2	3
Set up a Delivery Table	Set up a Delivery Table: 0	Set up a Delivery Table: 1	Set up a Delivery Table: 2	Set up a Delivery Table: 3
Set up a Caesarean Section Table	Set up a Caesarean Section Table: 0	Set up a Caesarean Section Table: 1	Set up a Caesarean Section Table: 2	Set up a Caesarean Section Table: 3
Scrub for a Caesarean Section	Scrub for a Caesarean Section: 0	Scrub for a Caesarean Section: 1	Scrub for a Caesarean Section: 2	Scrub for a Caesarean Section: 3
Circulate/Scrub for a Postpartum Tubal Ligation	Circulate/Scrub for a Postpartum Tubal Ligation: 0	Circulate/Scrub for a Postpartum Tubal Ligation: 1	Circulate/Scrub for a Postpartum Tubal Ligation: 2	Circulate/Scrub for a Postpartum Tubal Ligation: 3
Assist with an AROM (Artificial Rupture of Membranes) Procedure	Assist with an AROM (Artificial Rupture of Membranes) Procedure: 0	Assist with an AROM (Artificial Rupture of Membranes) Procedure: 1	Assist with an AROM (Artificial Rupture of Membranes) Procedure: 2	Assist with an AROM (Artificial Rupture of Membranes) Procedure: 3
Assist with Placement of Fetal Scalp Electrodes for Internal Monitoring	Assist with Placement of Fetal Scalp Electrodes for Internal Monitoring: 0	Assist with Placement of Fetal Scalp Electrodes for Internal Monitoring: 1	Assist with Placement of Fetal Scalp Electrodes for Internal Monitoring: 2	Assist with Placement of Fetal Scalp Electrodes for Internal Monitoring: 3
Assist with Fetal Scalp Blood Sampling	Assist with Fetal Scalp Blood Sampling: 0	Assist with Fetal Scalp Blood Sampling: 1	Assist with Fetal Scalp Blood Sampling: 2	Assist with Fetal Scalp Blood Sampling: 3
Assist with Placement of Intrauterine Pressure Cath for Internal Monitoring	Assist with Placement of Intrauterine Pressure Cath for Internal Monitoring: 0	Assist with Placement of Intrauterine Pressure Cath for Internal Monitoring: 1	Assist with Placement of Intrauterine Pressure Cath for Internal Monitoring: 2	Assist with Placement of Intrauterine Pressure Cath for Internal Monitoring: 3
Perform a Vaginal Exam-Assess Dilation,Effacement,Station & Presentation	Perform a Vaginal Exam-Assess Dilation,Effacement,Station & Presentation: 0	Perform a Vaginal Exam-Assess Dilation,Effacement,Station & Presentation: 1	Perform a Vaginal Exam-Assess Dilation,Effacement,Station & Presentation: 2	Perform a Vaginal Exam-Assess Dilation,Effacement,Station & Presentation: 3

ANTE/INTRAPARTUM, CARE OF: *This question is required.

Space Cell	0	1	2	3
Pregnancy-induced HTN	Pregnancy-induced HTN: 0	Pregnancy-induced HTN: 1	Pregnancy-induced HTN: 2	Pregnancy-induced HTN: 3
Preeclampsia & Eclampsia	Preeclampsia & Eclampsia: 0	Preeclampsia & Eclampsia: 1	Preeclampsia & Eclampsia: 2	Preeclampsia & Eclampsia: 3
Multiple Gestation	Multiple Gestation: 0	Multiple Gestation: 1	Multiple Gestation: 2	Multiple Gestation: 3
Placenta Previa	Placenta Previa: 0	Placenta Previa: 1	Placenta Previa: 2	Placenta Previa: 3
Abruptio Placenta	Abruptio Placenta: 0	Abruptio Placenta: 1	Abruptio Placenta: 2	Abruptio Placenta: 3
Malpresentations	Malpresentations: 0	Malpresentations: 1	Malpresentations: 2	Malpresentations: 3
Premature Labor	Premature Labor: 0	Premature Labor: 1	Premature Labor: 2	Premature Labor: 3
Diabetes Mellitus	Diabetes Mellitus: 0	Diabetes Mellitus: 1	Diabetes Mellitus: 2	Diabetes Mellitus: 3
Cardiac Disease	Cardiac Disease: 0	Cardiac Disease: 1	Cardiac Disease: 2	Cardiac Disease: 3
Asthma	Asthma: 0	Asthma: 1	Asthma: 2	Asthma: 3
Infectious Disease	Infectious Disease: 0	Infectious Disease: 1	Infectious Disease: 2	Infectious Disease: 3
Hemorrhage	Hemorrhage: 0	Hemorrhage: 1	Hemorrhage: 2	Hemorrhage: 3
Pyelonephritis	Pyelonephritis: 0	Pyelonephritis: 1	Pyelonephritis: 2	Pyelonephritis: 3
Cystitis	Cystitis: 0	Cystitis: 1	Cystitis: 2	Cystitis: 3
Sickle Cell Disease	Sickle Cell Disease: 0	Sickle Cell Disease: 1	Sickle Cell Disease: 2	Sickle Cell Disease: 3
Rh Incompatibilities	Rh Incompatibilities: 0	Rh Incompatibilities: 1	Rh Incompatibilities: 2	Rh Incompatibilities: 3
Oxytocin Challenge Test	Oxytocin Challenge Test: 0	Oxytocin Challenge Test: 1	Oxytocin Challenge Test: 2	Oxytocin Challenge Test: 3

INTERVENTIONS DURING LABOR *This question is required.

Space Cell	0	1	2	3
Provide Physical Comfort Measures and Emotional Support	Provide Physical Comfort Measures and Emotional Support: 0	Provide Physical Comfort Measures and Emotional Support: 1	Provide Physical Comfort Measures and Emotional Support: 2	Provide Physical Comfort Measures and Emotional Support: 3
Coach Psycholprophylactic Breathing & Relaxation Tech.	Coach Psycholprophylactic Breathing & Relaxation Tech.: 0	Coach Psycholprophylactic Breathing & Relaxation Tech.: 1	Coach Psycholprophylactic Breathing & Relaxation Tech.: 2	Coach Psycholprophylactic Breathing & Relaxation Tech.: 3
Support, Guide, Labor Coach PRN	Support, Guide, Labor Coach PRN: 0	Support, Guide, Labor Coach PRN: 1	Support, Guide, Labor Coach PRN: 2	Support, Guide, Labor Coach PRN: 3
Change Woman's Position PRN	Change Woman's Position PRN: 0	Change Woman's Position PRN: 1	Change Woman's Position PRN: 2	Change Woman's Position PRN: 3
Perineal Prep	Perineal Prep: 0	Perineal Prep: 1	Perineal Prep: 2	Perineal Prep: 3
Provide Care & Monitor After Rupture of Membranes	Provide Care & Monitor After Rupture of Membranes: 0	Provide Care & Monitor After Rupture of Membranes: 1	Provide Care & Monitor After Rupture of Membranes: 2	Provide Care & Monitor After Rupture of Membranes: 3
Fetal Heart Rate - Doppler	Fetal Heart Rate - Doppler: 0	Fetal Heart Rate - Doppler: 1	Fetal Heart Rate - Doppler: 2	Fetal Heart Rate - Doppler: 3
Fetal Heart Rate - Auscultate	Fetal Heart Rate - Auscultate: 0	Fetal Heart Rate - Auscultate: 1	Fetal Heart Rate - Auscultate: 2	Fetal Heart Rate - Auscultate: 3
Variability	Variability: 0	Variability: 1	Variability: 2	Variability: 3
Variable Decelerations	Variable Decelerations: 0	Variable Decelerations: 1	Variable Decelerations: 2	Variable Decelerations: 3
Spiral Electrode	Spiral Electrode: 0	Spiral Electrode: 1	Spiral Electrode: 2	Spiral Electrode: 3

INTERVENTIONS DURING DELIVERY *This question is required.

Space Cell	0	1	2	3
Spontaneous Vaginal Delivery	Spontaneous Vaginal Delivery: 0	Spontaneous Vaginal Delivery: 1	Spontaneous Vaginal Delivery: 2	Spontaneous Vaginal Delivery: 3
Emergency Delivery	Emergency Delivery: 0	Emergency Delivery: 1	Emergency Delivery: 2	Emergency Delivery: 3
Forceps Vaginal Delivery	Forceps Vaginal Delivery: 0	Forceps Vaginal Delivery: 1	Forceps Vaginal Delivery: 2	Forceps Vaginal Delivery: 3
Labor Room Delivery	Labor Room Delivery: 0	Labor Room Delivery: 1	Labor Room Delivery: 2	Labor Room Delivery: 3
General Anesthesia Monitoring	General Anesthesia Monitoring: 0	General Anesthesia Monitoring: 1	General Anesthesia Monitoring: 2	General Anesthesia Monitoring: 3
Epidural Anesthesia Monitoring	Epidural Anesthesia Monitoring: 0	Epidural Anesthesia Monitoring: 1	Epidural Anesthesia Monitoring: 2	Epidural Anesthesia Monitoring: 3
Spinal Anesthesia Monitoring	Spinal Anesthesia Monitoring: 0	Spinal Anesthesia Monitoring: 1	Spinal Anesthesia Monitoring: 2	Spinal Anesthesia Monitoring: 3
Local Infiltration (Preparation)	Local Infiltration (Preparation): 0	Local Infiltration (Preparation): 1	Local Infiltration (Preparation): 2	Local Infiltration (Preparation): 3
Immediate Care of Infant Post-birth (Suction & Weigh Infant)	Immediate Care of Infant Post-birth (Suction & Weigh Infant): 0	Immediate Care of Infant Post-birth (Suction & Weigh Infant): 1	Immediate Care of Infant Post-birth (Suction & Weigh Infant): 2	Immediate Care of Infant Post-birth (Suction & Weigh Infant): 3
Physically Examine Newborn (Anomalies, Respiratory Status)	Physically Examine Newborn (Anomalies, Respiratory Status): 0	Physically Examine Newborn (Anomalies, Respiratory Status): 1	Physically Examine Newborn (Anomalies, Respiratory Status): 2	Physically Examine Newborn (Anomalies, Respiratory Status): 3
Perform Cardiopulmonary Resuscitation: Adult	Perform Cardiopulmonary Resuscitation: Adult : 0	Perform Cardiopulmonary Resuscitation: Adult : 1	Perform Cardiopulmonary Resuscitation: Adult : 2	Perform Cardiopulmonary Resuscitation: Adult : 3
Perform Cardiopulmonary Resuscitation: Infant	Perform Cardiopulmonary Resuscitation: Infant: 0	Perform Cardiopulmonary Resuscitation: Infant: 1	Perform Cardiopulmonary Resuscitation: Infant: 2	Perform Cardiopulmonary Resuscitation: Infant: 3
Identify Infant Using Bracelet, Footprints, and Mother's Bands	Identify Infant Using Bracelet, Footprints, and Mother's Bands: 0	Identify Infant Using Bracelet, Footprints, and Mother's Bands: 1	Identify Infant Using Bracelet, Footprints, and Mother's Bands: 2	Identify Infant Using Bracelet, Footprints, and Mother's Bands: 3
Eye Prophylaxis	Eye Prophylaxis: 0	Eye Prophylaxis: 1	Eye Prophylaxis: 2	Eye Prophylaxis: 3
Collect Cord Blood Samples	Collect Cord Blood Samples: 0	Collect Cord Blood Samples: 1	Collect Cord Blood Samples: 2	Collect Cord Blood Samples: 3
Transfer to Newborn Nursery	Transfer to Newborn Nursery: 0	Transfer to Newborn Nursery: 1	Transfer to Newborn Nursery: 2	Transfer to Newborn Nursery: 3
Vacuum Extraction	Vacuum Extraction: 0	Vacuum Extraction: 1	Vacuum Extraction: 2	Vacuum Extraction: 3
Assist with High Risk Delivery	Assist with High Risk Delivery: 0	Assist with High Risk Delivery: 1	Assist with High Risk Delivery: 2	Assist with High Risk Delivery: 3
Shoulder Dystocia	Shoulder Dystocia: 0	Shoulder Dystocia: 1	Shoulder Dystocia: 2	Shoulder Dystocia: 3
Hemorrhage/Shock	Hemorrhage/Shock: 0	Hemorrhage/Shock: 1	Hemorrhage/Shock: 2	Hemorrhage/Shock: 3
Perineal Prep	Perineal Prep: 0	Perineal Prep: 1	Perineal Prep: 2	Perineal Prep: 3
Circulate for C-Section	Circulate for C-Section: 0	Circulate for C-Section: 1	Circulate for C-Section: 2	Circulate for C-Section: 3
Scrub for C-Section	Scrub for C-Section: 0	Scrub for C-Section: 1	Scrub for C-Section: 2	Scrub for C-Section: 3
Patient with General Anesthesia	Patient with General Anesthesia: 0	Patient with General Anesthesia: 1	Patient with General Anesthesia: 2	Patient with General Anesthesia: 3
Patient with Epidural Anesthesia	Patient with Epidural Anesthesia: 0	Patient with Epidural Anesthesia: 1	Patient with Epidural Anesthesia: 2	Patient with Epidural Anesthesia: 3
Circulate for Tubal Ligation	Circulate for Tubal Ligation: 0	Circulate for Tubal Ligation: 1	Circulate for Tubal Ligation: 2	Circulate for Tubal Ligation: 3
Scrub for Tubal Ligation	Scrub for Tubal Ligation: 0	Scrub for Tubal Ligation: 1	Scrub for Tubal Ligation: 2	Scrub for Tubal Ligation: 3
Assist with Placenta Delivery	Assist with Placenta Delivery: 0	Assist with Placenta Delivery: 1	Assist with Placenta Delivery: 2	Assist with Placenta Delivery: 3
Assist with Cervical Laceration Repair	Assist with Cervical Laceration Repair: 0	Assist with Cervical Laceration Repair: 1	Assist with Cervical Laceration Repair: 2	Assist with Cervical Laceration Repair: 3
Assist with Uterine Laceration Repair	Assist with Uterine Laceration Repair: 0	Assist with Uterine Laceration Repair: 1	Assist with Uterine Laceration Repair: 2	Assist with Uterine Laceration Repair: 3
Assist with Episiotomy Repair	Assist with Episiotomy Repair: 0	Assist with Episiotomy Repair: 1	Assist with Episiotomy Repair: 2	Assist with Episiotomy Repair: 3

POSTPARTUM PHASE *This question is required.

Space Cell	0	1	2	3
Postpartum Assessment	Postpartum Assessment: 0	Postpartum Assessment: 1	Postpartum Assessment: 2	Postpartum Assessment: 3
Fundus Consistency/Location	Fundus Consistency/Location: 0	Fundus Consistency/Location: 1	Fundus Consistency/Location: 2	Fundus Consistency/Location: 3
Initiate Fundal Massage PRN	Initiate Fundal Massage PRN: 0	Initiate Fundal Massage PRN: 1	Initiate Fundal Massage PRN: 2	Initiate Fundal Massage PRN: 3
Lochia	Lochia: 0	Lochia: 1	Lochia: 2	Lochia: 3
Bladder Distention	Bladder Distention: 0	Bladder Distention: 1	Bladder Distention: 2	Bladder Distention: 3
Insert Straight/Foley Catheter	Insert Straight/Foley Catheter: 0	Insert Straight/Foley Catheter: 1	Insert Straight/Foley Catheter: 2	Insert Straight/Foley Catheter: 3
Provide/Instruct Perineal Care	Provide/Instruct Perineal Care: 0	Provide/Instruct Perineal Care: 1	Provide/Instruct Perineal Care: 2	Provide/Instruct Perineal Care: 3
Episiotomy Care	Episiotomy Care: 0	Episiotomy Care: 1	Episiotomy Care: 2	Episiotomy Care: 3
Apply Ice to Perineum	Apply Ice to Perineum: 0	Apply Ice to Perineum: 1	Apply Ice to Perineum: 2	Apply Ice to Perineum: 3
C-section Incision Care	C-section Incision Care: 0	C-section Incision Care: 1	C-section Incision Care: 2	C-section Incision Care: 3
Assess Homan's Sign	Assess Homan's Sign: 0	Assess Homan's Sign: 1	Assess Homan's Sign: 2	Assess Homan's Sign: 3
Manage Postpartum Pain	Manage Postpartum Pain: 0	Manage Postpartum Pain: 1	Manage Postpartum Pain: 2	Manage Postpartum Pain: 3
Initiate Post-anesthesia Care: Spinal	Initiate Post-anesthesia Care: Spinal: 0	Initiate Post-anesthesia Care: Spinal: 1	Initiate Post-anesthesia Care: Spinal: 2	Initiate Post-anesthesia Care: Spinal: 3
Initiate Post-anesthesia Care: Epidural	Initiate Post-anesthesia Care: Epidural: 0	Initiate Post-anesthesia Care: Epidural: 1	Initiate Post-anesthesia Care: Epidural: 2	Initiate Post-anesthesia Care: Epidural: 3
Initiate Post-anesthesia Care:General	Initiate Post-anesthesia Care:General: 0	Initiate Post-anesthesia Care:General: 1	Initiate Post-anesthesia Care:General: 2	Initiate Post-anesthesia Care:General: 3
RhoGam Administration	RhoGam Administration: 0	RhoGam Administration: 1	RhoGam Administration: 2	RhoGam Administration: 3
Rubella Vaccine	Rubella Vaccine: 0	Rubella Vaccine: 1	Rubella Vaccine: 2	Rubella Vaccine: 3
Fundal Height	Fundal Height: 0	Fundal Height: 1	Fundal Height: 2	Fundal Height: 3
Fundal Massage	Fundal Massage: 0	Fundal Massage: 1	Fundal Massage: 2	Fundal Massage: 3
Lochia	Lochia: 0	Lochia: 1	Lochia: 2	Lochia: 3
Maternal Vital Signs	Maternal Vital Signs: 0	Maternal Vital Signs: 1	Maternal Vital Signs: 2	Maternal Vital Signs: 3
Recovering Post-Op C-Section Patient	Recovering Post-Op C-Section Patient: 0	Recovering Post-Op C-Section Patient: 1	Recovering Post-Op C-Section Patient: 2	Recovering Post-Op C-Section Patient: 3
Recovering Post-Op Tubal Ligation Patient	Recovering Post-Op Tubal Ligation Patient: 0	Recovering Post-Op Tubal Ligation Patient: 1	Recovering Post-Op Tubal Ligation Patient: 2	Recovering Post-Op Tubal Ligation Patient: 3
Fluid Balance	Fluid Balance: 0	Fluid Balance: 1	Fluid Balance: 2	Fluid Balance: 3
Assessment for DVT	Assessment for DVT: 0	Assessment for DVT: 1	Assessment for DVT: 2	Assessment for DVT: 3

PARENT/INFANT BOND *This question is required.

Space Cell	0	1	2	3
Foster Parent/Infant Bonding	Foster Parent/Infant Bonding: 0	Foster Parent/Infant Bonding: 1	Foster Parent/Infant Bonding: 2	Foster Parent/Infant Bonding: 3
Assist/Instruct Breastfeeding	Assist/Instruct Breastfeeding: 0	Assist/Instruct Breastfeeding: 1	Assist/Instruct Breastfeeding: 2	Assist/Instruct Breastfeeding: 3
Assist/Instruct Bottlefeeding	Assist/Instruct Bottlefeeding: 0	Assist/Instruct Bottlefeeding: 1	Assist/Instruct Bottlefeeding: 2	Assist/Instruct Bottlefeeding: 3
Discharge Teaching	Discharge Teaching: 0	Discharge Teaching: 1	Discharge Teaching: 2	Discharge Teaching: 3

AGE OF PATIENTS CARED FOR *This question is required.

Space Cell	0	1	2	3
Newborn (birth-30 days)	Newborn (birth-30 days): 0	Newborn (birth-30 days): 1	Newborn (birth-30 days): 2	Newborn (birth-30 days): 3
Infant (30 days - 1 year)	Infant (30 days - 1 year): 0	Infant (30 days - 1 year): 1	Infant (30 days - 1 year): 2	Infant (30 days - 1 year): 3
Toddler (1 - 3 years)	Toddler (1 - 3 years): 0	Toddler (1 - 3 years): 1	Toddler (1 - 3 years): 2	Toddler (1 - 3 years): 3
Preschooler (3 - 5 years)	Preschooler (3 - 5 years): 0	Preschooler (3 - 5 years): 1	Preschooler (3 - 5 years): 2	Preschooler (3 - 5 years): 3
School Age (5 - 12 years)	School Age (5 - 12 years): 0	School Age (5 - 12 years): 1	School Age (5 - 12 years): 2	School Age (5 - 12 years): 3
Adolescents (12 - 18 years)	Adolescents (12 - 18 years): 0	Adolescents (12 - 18 years): 1	Adolescents (12 - 18 years): 2	Adolescents (12 - 18 years): 3
Young Adults (18 - 39 years)	Young Adults (18 - 39 years): 0	Young Adults (18 - 39 years): 1	Young Adults (18 - 39 years): 2	Young Adults (18 - 39 years): 3
Middle Adults (39 - 64 years)	Middle Adults (39 - 64 years): 0	Middle Adults (39 - 64 years): 1	Middle Adults (39 - 64 years): 2	Middle Adults (39 - 64 years): 3
Older Adults (64+ years)	Older Adults (64+ years): 0	Older Adults (64+ years): 1	Older Adults (64+ years): 2	Older Adults (64+ years): 3

1. Candidate Signature

Clear

Signature of