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Please rate your experience / frequency (within the last year) using the following scale
(check the appropriate boxes below):

1 - No Experience / Theory Only
2 - Limited Experience / Need Review
3 - Frequent Experience / May Need Some Review
4 - Experienced / Perform Well

1 - Observed Only / Never Done
2 - Rarely Done (<6 times/year)
3 - Occasionally Done (1 - 2 times/month)
4 - Frequently Done (daily or weekly)

	Experience				Frequency
GENERAL SKILLS	1	2	3	4	1	2	3	4
Patient and Family Teaching
Coaching Needs: Physical and Emotional
Universal Precautions
Care of the Patient in Isolation
Care of the Patient in Restraints
Cardiac Monitoring
Pulse Oximetry
Ventilator Management (Adult)
Ventilator Management (Newborn)
Prep and Administration of Emergency Meds
Infant/Neonatal Cardiac/Respiratory Arrest
Adult Cardiac/Respiratory Arrest
End of Life Care
Fetal Monitoring - Basic
Fetal Monitoring - Advanced
IV Therapy
Administration of Blood/Blood Products
Knowledge of Normal Lab Values
Newborn
Labor Patient
Pain Management
Automated Medication Dispensing System
CARE OF THE PATIENT W/ PRE-EXISTING CONDITIONS/HIGH RISK OB	1	2	3	4	1	2	3	4
Cardiac Disease
Neurological Disease
Seizure Disorder
Chronic Diabetes Mellitus
Pregnancy Induced Diabetes Mellitus
Asthma
Chronic Hypertension
Pregnancy-Induced Hypertension
Infectious Disease
HBV
HIV
Sickle Cell Disease
RH Incompatibilities
Hemolytic Anemia
Collagen Vascular Disease
Hemorrhage
Drug Addiction/Withdrawal
Pyelonephritis
Abruptio Placenta
Placenta Previa
Placenta Acreta
Preeclampsia
Eclampsia
Premature Labor
Malpresentations
Breech
Transverse Lie/Shoulder
Face Presentation
Brow Presentation
Multiple Gestation
PROM
Chorioamnionitis
Poly/Oligohydramnios
Prior Tubal Ligation
VBAC Management/Trial of Labor
Uterine Rupture
Incompetent Cervix (Shirodkar Suture/Cerclage)
Spontaneous Abortions - Complete/Incomplete
Intrauterine Growth Retardation (IUGR)
Postdate Pregnancy
HELLP Syndrome
DIC
Fetal Demise
ANTEPARTUM	1	2	3	4	1	2	3	4
Triage of Obstetrical Patients
Assessment of Birth Plan
Perform Admission Risk Assessment
Non-Stress Test (NST)
Induction of Labor
Oxytocin Challenge Tests (OCT)
Biophysical Profile
Assist with Sonogram
Perform Sonogram
Assist with Amniocentesis
Normal Perinatal Vital Signs
Deep Tendon Reflex Checks (DTR's)
Edema Assessment
Clonus
Assess for Comfort
Breathing/Relaxation Techniques
Coaching
Positioning
MEDICATIONS	1	2	3	4	1	2	3	4
Ritodrine
Magnesium Sulfate
Terbutaline
Indomethacin
Procardia
Pitocin
Oxytocin
Cervidil
Cytotec
Prostin Suppositories
Assist with Prostin Gel
Antibiotics
Antihypertensives
Heparin
Stadol
Nubain
Morphine
Demerol
Fentanyl
Insulin Drips
Insulin Pumps
Insulin SC
AZT/Other Antiviral Medications
Rhogam
IV THERAPY/PROCEDURES	1	2	3	4	1	2	3	4
Starting PIV's
PICC Lines-Care and Maintenance
Central Venous Lines-Care and Maintenance
Invasive Hemodynamic Monitoring
Blood Draw from PICC/CVL
Administration of Blood/Blood Products
Packed Red Blood Cells
Platelets
IV Infusion Pumps
Blood/Fluid Warmers
LABOR ASSESSMENT / PROCEDURES: MATERNAL	1	2	3	4	1	2	3	4
Normal Vital Signs - Baseline
Identify Common Cardiac Arrhythmias
Assist with Sterile Speculum Exam
Perform Sterile Speculum Exam
Vaginal Exam - Manual
Status of Membranes
Assist with Rupture of Membranes
Fern Test
Nitrazine
Presence of Clonus
DTR's
Edema
Progression of Labor
Dilation
Effacement
Fetal Position
Fetal Presentation
Station
Contraction Characteristics
Determination of Fetal Head Position
Documentation of Labor Status and Interventions
Labor Suppressants
Collect Blood Specimens
Collect Urine Specimens
Toxicology Studies
Collect Vaginal Cultures
Fluid
Herpes
Chlamydia
Group B Strep
Perform Leopold's Maneuvers
Amnioinfusion (assist or perform) for
Variable Decelerations
Meconium
Prolapsed Cord
Vasa Previa
Catheter Insertion
Straight Cath
Foley

	Experience				Frequency
LABOR ASSESSMENT / PROCEDURES: FETAL	1	2	3	4	1	2	3	4
Fetal Heart Rate - Doppler
Fetal Heart Rate - Auscultate
Document Fetal Position
Fetal Heart Rate Patterns: Identify Baseline
Fetal Heart Rate Patterns: Identify & Treat
Variability
Variable Decelerations
Early Decelerations
Late Decelerations
Prolonged Decelerations
External Fetal Monitor Application
Internal Fetal Monitor Application (Assist)
Internal Fetal Monitor Application (Perform)
Spiral Electrode
Intrauterine Pressure Catheter (IUPC)
Placement
Calibration
Fluid Filled
Transducer Tipped
DELIVERY/C-SECTION	1	2	3	4	1	2	3	4
Assist with Vaginal Delivery
Forceps Extraction
Vacuum Extraction
Assist with High Risk Delivery
Shoulder Dystocia
Hemorrhage/Shock
Emergency Delivery
Abdominal Shave/Scrub Prep
Perineal Prep
Circulate for C-Section
Scrub for C-Section
Patient with General Anesthesia
Patient with Epidural Anesthesia
Circulate for Tubal Ligation
Scrub for Tubal Ligation
Assist with Placenta Delivery
Fundus Massage
Assist with Cervical Laceration Repair
Assist with Uterine Laceration Repair
Assist with Episiotomy Repair
IMMEDIATE CARE OF NEWBORN IN DELIVERY ROOM	1	2	3	4	1	2	3	4
Newborn Assessment
Ballard
Dubowitz
Finnegan/Abstinence Scoring
Apgar Scores
Initial Vital Signs
Suctioning
Bulb
Delee
Wall
Meconium Aspiration
Collect Cord Samples
Assist with UAC/UVC Insertion
Insertion of IV, Including Scalp IV
Radiant Warmer/Thermoregulation
Interventions for LGA, SGA, IUGR
Interventions for Infant of Diabetic Mother
Oxygen Administration
Bag/Mask Ventilation of the Newborn
Assist with Intubation
Transport Isolette
Heelstick Glucose
Medications
Eye Prophylaxis
Vitamin K
ID/Security Banding
Promote Bonding Behaviors
Lead Placement for Cardiac Monitor
Apnea Monitoring
Oxyhood
POSTPARTUM CARE	1	2	3	4	1	2	3	4
Fundal Height
Fundal Massage
Lochia
Episiotomy Care
Perineum Care
Maternal Vital Signs
Recovering Post-Op C-Section Patient
Recovering Post-Op Tubal Ligation Patient
Fluid Balance
Assessment for DVT
Couplet Care
Breast Care
Breastfeeding
NEWBORN CARE	1	2	3	4	1	2	3	4
Cord Care
Circumcision Care
Bath Demonstration
Assist with Breastfeeding
Latch on
Positioning
Assist with Lumbar Puncture
Administration of IV Antibiotics
Newborn Vital Signs
CARE OF THE INFANT WITH	1	2	3	4	1	2	3	4
Drug Addiction/Withdrawal
Cystic Fibrosis
Meconium Aspiration
Pneumonia
Pulmonary Edema
RDS
NEC
Cardiac Anomolies
Neuromuscular Disease
Spina Bifida
Seizure Activity
Tracheoesophageal Fistula
Sepsis
Sickle Cell Diease
Low Birth Weight Infants
PAIN MANAGEMENT / ANESTHESIA	1	2	3	4	1	2	3	4
Assess Pain Level
Assess Acceptable Level of Pain
Intranasal Pain Medications
Oral Pain Medications
IV Pain Medications
PCA
IV Conscious Sedation
Epidural Pain Management
Intervention for Anesthesia Toxicity
Assist with Epidural Insertion
Positioning of Patient
Signs of a Dural Puncture
Coaching Patient
Fluid Challenge
Hypotension
Intrathecal Narcotics
AGE SPECIFIC COMPETENCY	1	2	3	4	1	2	3	4
Newborn/Neonate (birth to 30 days)
Infant (1 month to 1 year)
Toddler (1 year to 3 years)
Preschooler (3 years to 5 years)
School age child (5 years to 12 years)
Adolescents (12 years to 18 years)
Young Adults (18 years to 39 years)
Middle Adults (39 years to 64 years)
Older Adults (64 years to 79 years)
Elderly Adults (over 79+ years)

I attest that the information I have given is true and accurate to the best of my knowledge and that I am the indivdual completing this form. I hereby authorize Texas Select Staffing to release this Skills Checklist to its client facilities for consideration of employment as a contractor at those facilities.