LABOR & DELIVERY EXPERIENCE PROFILE

First Name: Last Name:Grad from nursing school:

Degree: RNC N/A NRP N/A

State of original License:

State of current License:

Phone Number:

Please indicate your level of experience with the following patient groups and clinical skills category according to the number of years of experience indicated below:

CATEGORIES 0, 1, 2, 3

0=No experience
1=limited experience
2=perform with review
3=perform independently

	PATIENT GROUPS	0	1	2	3
	Neonate
	Infant
	Children
	Adolescent
	Adult
	Geriatric
OBSTERICAL NURSING

OBSTETRICAL ASSESSMENT SKILLS
Inbound facility tranfer unit
Outbound transfer to other facility
Identify fetal position (Leopold maneuvers)
Fetal heart tones
Severity of contractions
Vaginal exam, dilitation & effacement
Vaginal exam, station & presentation
Vaginal exam, culture collection

CLINICAL SKILLS
Set up tocotransducer
Intrauterine pressure catheter
Auscultate fetal heart tones
Intact/nonintact membranes
Nitrazine test
Internal fetal monitor
Interpreting normal/abnormal fetal heart patterns
Baseline interpretation
Early decelerations
Beat to beat variability
Late decelerations
Prolonged decelerations
Set up OB pack
Set up baby pack
Cord blood collection
Artificial rupture of membranes

COMPLICATIONS
Pregnancy Induced Hypertension
Antihypertensives
Clonus
Diabetes
Abruptio placenta
Placenta previa
Prolapsed cord
Preeclampsia
Eclampsia
Malpresentation
Premature rupture of the membranes
Premature labor
Magnesium sulfate
Drug dependent
RH incompatibility
Herpes
HIV
HBV
Hemorrhage
Blood transfusion
Forceps delivery
Vacuum extraction
Precipitous delivery
Starting IV's
Cesarean section-circulate
Cesarean section-scrub
Central line placement, set up & assist
Epidural, set up & assist
Spinal, set up & assist
Local, set up & assist
Foley catheter placement
Pain control, narcotic
Intrathecal medication delivery
Episiotomy, set up & assist
Uterine massage
Lochia assessment
DVT
Induction of labor
Cytotec
Prostaglandin supp
Oxytocin infusion

PATIENT TEACHING
Relaxation/breathing techniques
Premature labor prevention
Phone triage
Breast feeding
CPR for neonates

LABOR & DELIVERY NURSING WORK HISTORY
TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:


TO NAME OF HOSPITAL:
SUPERVISOR NAME:
NUMBER OF HOSPITAL BEDS:
NUMBER OF BEDS ON UNIT:
PATIENT TYPES		LDRP
TRAVEL ASSIGNMENT?
DESCRIPTION OF DUTIES:

Authorization (Please type your name and the date.)

By submitting this application, I hereby certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

Signature Date

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