Mother Baby

Provision of CareProficiencyFrequency

Assess Pain and alternative non-parmacologic
comfort measures used to assist in alleviation
of pain

1

2

3

4

1

2

3

4

Provide care to at-risk patients(i.e.:fall,
precaution, seizure precautions,bleeding
precautions,aspiration precautions)

1

2

3

4

1

2

3

4

Provide customer service oriented care such as
responding to patient and family member
questions and need in a timely manner

1

2

3

4

1

2

3

4

Provide support in family adaptation situations
i.e.:adoption,surrogacy,teenage mother

1

2

3

4

1

2

3

4

Recognize appropriate interactions between
mother and infant to ensure adequate bonding

1

2

3

4

1

2

3

4

Mechanisms of heat lossProficiencyFrequency

Understands physiologic mechanisms(i.e..
Conduction,Convection,Evaporation,Insensible
water loss, Radiation)

1

2

3

4

1

2

3

4

Swadding techniques

1

2

3

4

1

2

3

4

Temparature maintenance i.e.: infant warmers

1

2

3

4

1

2

3

4

Assist with common procedures done by a licenced independent practitioner at the bedside:ProficiencyFrequency

Circumcision

1

2

3

4

1

2

3

4

D&C

1

2

3

4

1

2

3

4

Epidural catheter pumps

1

2

3

4

1

2

3

4

Epidural catheter removal

1

2

3

4

1

2

3

4

IV Conscious Sedation

1

2

3

4

1

2

3

4

PICC line placement

1

2

3

4

1

2

3

4

EquipmentProficiencyFrequency

Apnea Monitor

1

2

3

4

1

2

3

4

Cardiac Monitor

1

2

3

4

1

2

3

4

Infant warmers

1

2

3

4

1

2

3

4

IV Pumps

1

2

3

4

1

2

3

4

Oxygen flow meter

1

2

3

4

1

2

3

4

Oxygen tubing

1

2

3

4

1

2

3

4

Patient beds

1

2

3

4

1

2

3

4

PCA Pumps

1

2

3

4

1

2

3

4

Phototherapy

1

2

3

4

1

2

3

4

Sequential compression devices

1

2

3

4

1

2

3

4

Suction catheters

1

2

3

4

1

2

3

4

Suctioning equipment

1

2

3

4

1

2

3

4

Urine drainage bags

1

2

3

4

1

2

3

4

Vital sign equipment

1

2

3

4

1

2

3

4

Wound drainage devices

1

2

3

4

1

2

3

4

Maternal Assessment/Management
Perform maternal assessment:ProficiencyFrequency

Bowel sounds

1

2

3

4

1

2

3

4

Breast Engorgement

1

2

3

4

1

2

3

4

Cardiovascular System

1

2

3

4

1

2

3

4

DTR

1

2

3

4

1

2

3

4

Episiotomy

1

2

3

4

1

2

3

4

Fundal Height

1

2

3

4

1

2

3

4

Gastrointestinal System

1

2

3

4

1

2

3

4

Genitourinary System

1

2

3

4

1

2

3

4

Heart sounds

1

2

3

4

1

2

3

4

Incision site

1

2

3

4

1

2

3

4

Integumentary

1

2

3

4

1

2

3

4

Laceration

1

2

3

4

1

2

3

4

Location/position of uterus

1

2

3

4

1

2

3

4

Lung sounds

1

2

3

4

1

2

3

4

Neurological assessment

1

2

3

4

1

2

3

4

Parental/infant interaction

1

2

3

4

1

2

3

4

Perineum(hematoma/hemorrhoids)

1

2

3

4

1

2

3

4

Presence, amount, color and odor of lochia

1

2

3

4

1

2

3

4

Interpretation of Lab Results:ProficiencyFrequency

Chemistry

1

2

3

4

1

2

3

4

Coagulation Studies

1

2

3

4

1

2

3

4

Provision of care in lactation process:ProficiencyFrequency

Breast engorgement

1

2

3

4

1

2

3

4

Feeding cues

1

2

3

4

1

2

3

4

Mastitis

1

2

3

4

1

2

3

4

Maternal nutritional needs

1

2

3

4

1

2

3

4

Nipple problems

1

2

3

4

1

2

3

4

Positioning

1

2

3

4

1

2

3

4

Proper latch

1

2

3

4

1

2

3

4

Suck/swallow sequence

1

2

3

4

1

2

3

4

Perform:ProficiencyFrequency

Adult CPR

1

2

3

4

1

2

3

4

Dressing changes

1

2

3

4

1

2

3

4

Foley catheter insertion

1

2

3

4

1

2

3

4

Nasogastric tube placement

1

2

3

4

1

2

3

4

Peri-care

1

2

3

4

1

2

3

4

Peripheral IV catheter placement

1

2

3

4

1

2

3

4

Straight catheterization

1

2

3

4

1

2

3

4

Wound care

1

2

3

4

1

2

3

4

Collection and labeling of blood specimen

1

2

3

4

1

2

3

4

Collection and labeling of sputum specimen

1

2

3

4

1

2

3

4

Collection and labeling of stool specimen

1

2

3

4

1

2

3

4

Collection and labeling of urine specimen

1

2

3

4

1

2

3

4

Collection and labeling of wound drainage specimen

1

2

3

4

1

2

3

4

Correct sterile technique when performing
procedures such as dressing changes

1

2

3

4

1

2

3

4

End of life care and post-mortem care
for mother/infant

1

2

3

4

1

2

3

4

Measurement of intake and output as part
of the plan of care

1

2

3

4

1

2

3

4

Recognize maternal abnormalities:ProficiencyFrequency

Abnormal blood glucose levels

1

2

3

4

1

2

3

4

Abnormal intake and output

1

2

3

4

1

2

3

4

Abnormal lab values

1

2

3

4

1

2

3

4

Abnormal vital signs

1

2

3

4

1

2

3

4

Interpretation of normal/abnormal oxygen
saturations

1

2

3

4

1

2

3

4

Signs/symptoms Amniotic fluid disorders

1

2

3

4

1

2

3

4

Signs/symptoms DIC

1

2

3

4

1

2

3

4

Signs/symptoms Eclampsia

1

2

3

4

1

2

3

4

Signs/symptoms gestational diabetes

1

2

3

4

1

2

3

4

Signs/symptoms infectious diseases

1

2

3

4

1

2

3

4

Signs/symptoms maternal hemmorhage

1

2

3

4

1

2

3

4

Signs/symptoms retained placenta

1

2

3

4

1

2

3

4

Provision of Care in the GYN patient:ProficiencyFrequency

A&P repair

1

2

3

4

1

2

3

4

Hysterectomy

1

2

3

4

1

2

3

4

Pelvic support procedures

1

2

3

4

1

2

3

4

PID

1

2

3

4

1

2

3

4

Recognize:ProficiencyFrequency

Signs and symptoms of abuse, neglect in
mother/newborn

1

2

3

4

1

2

3

4

Signs and symptoms of drug and alcohol
dependence/withdrawal in mother/newborn

1

2

3

4

1

2

3

4

Newborn Assessment/Management
Perform newborn assessment:ProficiencyFrequency

APGAR scores

1

2

3

4

1

2

3

4

Ballard Scale

1

2

3

4

1

2

3

4

Bowel sounds

1

2

3

4

1

2

3

4

Cardiovascular System

1

2

3

4

1

2

3

4

Cord gases

1

2

3

4

1

2

3

4

DTR

1

2

3

4

1

2

3

4

Gastrointestinal System

1

2

3

4

1

2

3

4

Genitourinary System

1

2

3

4

1

2

3

4

Heart sounds(Apical)

1

2

3

4

1

2

3

4

Integumentary

1

2

3

4

1

2

3

4

Lung sounds

1

2

3

4

1

2

3

4

Motor skills

1

2

3

4

1

2

3

4

Neurological assessment

1

2

3

4

1

2

3

4

Pain cues

1

2

3

4

1

2

3

4

Respiratory effort

1

2

3

4

1

2

3

4

Temperature

1

2

3

4

1

2

3

4

Recognize newborn abnormalities:ProficiencyFrequency

Abnormal blood glucose levels

1

2

3

4

1

2

3

4

Abnormal intake and output

1

2

3

4

1

2

3

4

Abnormal lab values

1

2

3

4

1

2

3

4

Abnormal sleep patterns

1

2

3

4

1

2

3

4

Abnormal vital signs

1

2

3

4

1

2

3

4

Abnormal weight

1

2

3

4

1

2

3

4

Bowel Obstruction

1

2

3

4

1

2

3

4

Chorioamnionitis

1

2

3

4

1

2

3

4

Chromosomal abnormalities

1

2

3

4

1

2

3

4

Cleft palate/lip

1

2

3

4

1

2

3

4

Conjuctivitis

1

2

3

4

1

2

3

4

Diabetes

1

2

3

4

1

2

3

4

Down Syndrome

1

2

3

4

1

2

3

4

Epsteins pearls

1

2

3

4

1

2

3

4

Erythema toxicum

1

2

3

4

1

2

3

4

GBS (Group B Strep)

1

2

3

4

1

2

3

4

Genetic disorders

1

2

3

4

1

2

3

4

Hydrocephalus

1

2

3

4

1

2

3

4

Hyperbilirubinemia

1

2

3

4

1

2

3

4

Hypothermia

1

2

3

4

1

2

3

4

Interpretation of abnormal oxygen saturations

1

2

3

4

1

2

3

4

Meconium aspiration

1

2

3

4

1

2

3

4

Mongolian spots

1

2

3

4

1

2

3

4

Mother to Infant transmission i.e.:Sexually
transmitted infections

1

2

3

4

1

2

3

4

Premature infant

1

2

3

4

1

2

3

4

Respiratory distress syndrome

1

2

3

4

1

2

3

4

Rh disease and ABO compatibility

1

2

3

4

1

2

3

4

S/S drug/alcohol withdrawal

1

2

3

4

1

2

3

4

Sepsis

1

2

3

4

1

2

3

4

Shoulder dystocia

1

2

3

4

1

2

3

4

Signs of dehydration

1

2

3

4

1

2

3

4

Signs of hypoglycemia

1

2

3

4

1

2

3

4

Umbilical Hernia

1

2

3

4

1

2

3

4

Mother Baby Pharmacology
Administration:ProficiencyFrequency

Antibiotics

1

2

3

4

1

2

3

4

d-TAP

1

2

3

4

1

2

3

4

Erythromycin ointment

1

2

3

4

1

2

3

4

Hep B vaccination

1

2

3

4

1

2

3

4

Magnesium sulfate

1

2

3

4

1

2

3

4

Narcotic analgesics

1

2

3

4

1

2

3

4

Oxytocin

1

2

3

4

1

2

3

4

Rhogam

1

2

3

4

1

2

3

4

Rubella

1

2

3

4

1

2

3

4

Vitamin K

1

2

3

4

1

2

3

4

Professional Practice
Serve as patient advocate for both mother and infant:ProficiencyFrequency

Collaborate with social services and other health
care professionals in the patient’s plan of care

1

2

3

4

1

2

3

4

Communicate findings to appropriate
caregiver/providers

1

2

3

4

1

2

3

4

Communicate with culturally diverse populations
through chaplains

1

2

3

4

1

2

3

4

Communicate with culturally diverse populations
through interpreters

1

2

3

4

1

2

3

4

Communicate with culturally diverse populations
social services

1

2

3

4

1

2

3

4

Evaluate outcomes based upon analysis of
assessment data

1

2

3

4

1

2

3

4

Independently make decisions, problem solve,and
use critical thinking in caring for mother and infant

1

2

3

4

1

2

3

4

Report relevant information to physician

1

2

3

4

1

2

3

4

Implement Conflict resolution techniques used
to de-escalate stressful situations

1

2

3

4

1

2

3

4

Participate in organizational emergency response plans:ProficiencyFrequency

Bomb threat

1

2

3

4

1

2

3

4

Cardiac arrest

1

2

3

4

1

2

3

4

Fire

1

2

3

4

1

2

3

4

Infant abduction

1

2

3

4

1

2

3

4

Rapid response

1

2

3

4

1

2

3

4

Tornado

1

2

3

4

1

2

3

4

Participate:ProficiencyFrequency

Completion of incident or variance reports

1

2

3

4

1

2

3

4

Data collection in PI process

1

2

3

4

1

2

3

4

Events or issues reportable to the state board of
nursing such as impairment, diversion, fraud,
safe harbor

1

2

3

4

1

2

3

4

QA initiatives

1

2

3

4

1

2

3

4

Legal/RegulatoryProficiencyFrequency

Follow HIPAA guidelines

1

2

3

4

1

2

3

4

Obtaining informed consent

1

2

3

4

1

2

3

4

Delegation:ProficiencyFrequency

LPNs/LVNs

1

2

3

4

1

2

3

4

Nursing assistants

1

2

3

4

1

2

3

4

Implement 5 Rights of Delegation

1

2

3

4

1

2

3

4

Link patients to community resources:ProficiencyFrequency

Durable medical equipment/companies

1

2

3

4

1

2

3

4

Home health care

1

2

3

4

1

2

3

4

Local health department

1

2

3

4

1

2

3

4

Social services

1

2

3

4

1

2

3

4

Subsidized providers e.g. WIC , CHIP

1

2

3

4

1

2

3

4

Mother Baby Education
Utilize various modalities for patient/family education :ProficiencyFrequency

Brochures

1

2

3

4

1

2

3

4

Closed circuit TV videos

1

2

3

4

1

2

3

4

Computers

1

2

3

4

1

2

3

4

Pamphlets

1

2

3

4

1

2

3

4

Verbal Communication

1

2

3

4

1

2

3

4

Videos

1

2

3

4

1

2

3

4

Written Communication

1

2

3

4

1

2

3

4

Provide education:ProficiencyFrequency

Apnea monitoring

1

2

3

4

1

2

3

4

Bottle feeding techniques and equipment used

1

2

3

4

1

2

3

4

Circumcision

1

2

3

4

1

2

3

4

Contraceptive counseling

1

2

3

4

1

2

3

4

Cord care

1

2

3

4

1

2

3

4

Diarrhea

1

2

3

4

1

2

3

4

Elimination patterns in bottle feeding

1

2

3

4

1

2

3

4

Fever

1

2

3

4

1

2

3

4

Follow up care for newborn with primary
health care provider

1

2

3

4

1

2

3

4

Hygiene

1

2

3

4

1

2

3

4

Infant caretaking skills

1

2

3

4

1

2

3

4

Infant CPR

1

2

3

4

1

2

3

4

Jaundice

1

2

3

4

1

2

3

4

Latch-on techniques

1

2

3

4

1

2

3

4

Nipple care

1

2

3

4

1

2

3

4

Nutritional needs in bottle feeding

1

2

3

4

1

2

3

4

PKU

1

2

3

4

1

2

3

4

Positioning

1

2

3

4

1

2

3

4

Post Cesarean Care

1

2

3

4

1

2

3

4

Required immunizations/schedule

1

2

3

4

1

2

3

4

Routine Discharge teaching

1

2

3

4

1

2

3

4

Signs of adequate intake

1

2

3

4

1

2

3

4

Supplemental feedings

1

2

3

4

1

2

3

4

Use of breast pump (manual/electric)

1

2

3

4

1

2

3

4

Warning Signs

1

2

3

4

1

2

3

4

Age SpecificProficiencyFrequency

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

Infant (Birth to 1 year)

1

2

3

4

1

2

3

4

Toddler (1-3 years)

1

2

3

4

1

2

3

4

Pre-school (3-6 years)

1

2

3

4

1

2

3

4

School Age (6-12 years)

1

2

3

4

1

2

3

4

Adolescent (12-18 years)

1

2

3

4

1

2

3

4

Young Adult (18-30 years)

1

2

3

4

1

2

3

4

Mature Adult (30-60 years)

1

2

3

4

1

2

3

4

Elderly (>60 years)

1

2

3

4

1

2

3

4

Years Experience in Clinical Speciality :

Most recent facility worked at :

* I hereby certify that ALL information I have provided to Clover Health Services, on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Proficiency : -	1 = Never Performed	2 = Limited Experience	3 = Comfortable Performing	4 = Proficient
Frequency : -	1 = Never	2 = Sometimes	3 = Often	4 = Always