N365P

Nursing Care of Childbearing

Families Practicum
Marta Anderson RN MSN
(Course Facilitator)

#58815, 58820, 58825,

58830, 58835, 58840

Spring 2012
The University of Texas at Austin
School of Nursing
N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Table of Contents

Placement ................................................................................................................................. 2
Course Credit ........................................................................................................................... 2
Prerequisites ............................................................................................................................. 2
Facilitator ................................................................................................................................. 2
Faculty...................................................................................................................................... 2
Office Hours............................................................................................................................. 2
Course Description................................................................................................................... 2
Course Objectives .................................................................................................................... 3
Clinical Time ........................................................................................................................... 3
Required Textbooks ................................................................................................................. 3
Recommended Textbook ......................................................................................................... 3
Recommended DVD ................................................................................................................ 3
Teaching/Learning Strategies .................................................................................................. 4
Course Policies......................................................................................................................... 4
In Case of Emergency .............................................................................................................. 9
Course Schedule..................................................................................................................... 11
Evaluation and Grading ......................................................................................................... 15
Assignments and Percent of Grade ............................................................................ 15
Introductory Lecture/Clinical Series .......................................................................... 15
Clinical Practicum.................................................................................................................. 16
Clinical Performance ............................................................................................................. 16
Clinical Conference ............................................................................................................... 16
Clinical Preparation/Online Tests .......................................................................................... 16
Exemplar Patient Presentation ............................................................................................... 17
Exemplar Patient Presentation Grading Criteria .................................................................... 18
Nursing Process Reports ........................................................................................................ 19
NPR Instructions .................................................................................................................... 19
Nursing Process Report Grading Rubric................................................................................ 20
Expected Behaviors for All Clinical Experiences ................................................................. 21
Guidelines for Childrearing Grade Determination ................................................................ 23
Student Data Sheet ................................................................................................................. 26
Clinical Objectives for Care of the Family During the Postpartum Period ........................... 27
Postpartum Data Sheet ............................................................................................... 29
Clinical Objectives for Care of the Family During the Intrapartum Period .......................... 33
Labor and Birth Data Sheet........................................................................................ 35
Clinical Objectives for Care of the Newborn ........................................................................ 38
Newborn Data Sheet .................................................................................................. 40
Childbearing Clinical Component - Evaluation Tool ............................................................ 44

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Placement: First Semester, Senior Year

Course Credit: Three semester hours based on 16 hours/week for seven weeks

Prerequisites: Successful completion of all J1 and J2 courses, and concurrent enrollment

in or completion of N265. A score of 90% or higher on the Medications
and Calculations Test is required before your first day in the clinical
setting.

Facilitator: Marta Anderson, MSN, RN

Office: NUR 5.163
Phone: 232-4706
E-mail: manderson@mail.nur.utexas.edu

Faculty Sybil Bowers Momii, RNC-OB, MSN

Office: NUR 5.172
Phone: 471-9840
E-mail: smomii@mail.nur.utexas.edu

Faculty: Sakre Heinze, RN, MSN

Office: NUR 5.102K
Phone: 475-8694
E-mail: sheinze@mail.nur.utexas.edu

Faculty: Janiece Walker, RN, MSN

Office: NUR 2.308
Phone: 232-4846
E-mail: jl_walker@mail.utexas.edu

Office Hours: TBA

Course Description: This course is the clinical application of the concepts, theories, processes
and skills presented in the co-requisite courses and which are pertinent to the care of women and
their families during the childbearing years. The primary settings for student learning are the
maternity units of local acute care hospitals.

The syllabus will be posted on blackboard.

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N365P Spring 2012

Course Objectives: At the conclusion of this course the student should be able to:

1. Integrate theoretical and empirical knowledge from nursing, physical, and behavioral
sciences into the nursing care of childbearing families.

2. Incorporate knowledge, psychomotor and interpersonal nursing skills in caring for

women and their families or support systems in a variety of clinical settings.

3. Apply nursing process to the care of women and their families or support systems during
the childbearing period.

4. Collaborate with other members of the health care team in providing care to families
during the childbearing period.

5. Practice responsibility and accountability for performing nursing actions and evaluating
the results of those actions.

6. Practice nursing according to legal, ethical, and professional standards.

7. Select and utilize nursing research findings which relate to nursing care of families and
infants.

Clinical Time: Each clinical group meets for 16 hours/week (Mondays and Tuesdays) every
week for seven weeks. The schedule is coordinated with companion course
N265, as most students take both courses concurrently.

Required Textbooks:

Lowdermilk, D. L., Perry, S. E., & Cashion, M. C. (2010). Maternity nursing (8th ed.). St. Louis,
MO: Mosby (ISBN: 978-0-323-06661-7).

Nursing Process book required for J1 and J2

Lab text required for J1 and J2

Recommended Textbook:

Green, C. J. (2012). Maternal newborn nursing care plans (2nd ed.). Independence, MO: Jones
& Bartlett Learning.

Recommended DVD:

Mosby’s nursing video skills: Maternal-newborn & women’s health (2007). St. Louis: Mosby.

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N365P Spring 2012

Teaching/Learning Strategies:
• Clinical practicum
• Research article and exemplar patient presentation
• Nursing process reports and data sheets
• Online tests (as evidence of clinical preparation)
• Post-tests on designated material presented in class/lab sessions
• Simulation Lab sessions

Course Policies:

Minimum Grade Criteria: Students must earn a "C" in each clinical performance component of
the course (the childbearing component and childrearing component), before the grades
will be tabulated for the course grade.

Policy on Failure to Maintain Minimal Standards of Safety: Failure to demonstrate safe

performance of the three critical elements constitutes failure in the course, regardless of
nursing care proficiency in performing other behaviors or written work.

Policy on Removal from Clinical Setting: Consistent performance of the three critical elements
of nursing care practice is expected. Students who demonstrate a pattern of failure in any
one of these three critical elements will be removed from the clinical setting and not
allowed to progress to other clinical areas.

Attendance Policy: Students are expected to attend all clinical sessions. This includes classes in
the Skills Lab and Clinical Practicum lab days in various clinical agencies and
community settings. Failure to appear for scheduled clinical practicum sessions and
tardiness are viewed as unprofessional behavior. Students who are absent or tardy may be
required to complete alternate assignments at the instructor's discretion. Students may be
dropped from a practicum course or may receive a failing grade for patterns of absences
or tardiness. Please consult each course syllabus for the specific attendance policy for
each course.

If students find it impossible to be present for a clinical practicum, arrangements must be

made with the instructor in advance. Failure to notify the instructor (via phone, no e-mail
messages) may result in a reduction of one letter grade from the final course grade.

“No credit” for the course will result if the student has two unexcused absences or two
unacceptable reasons for missing lab.

Course Repeat Policy: A student may repeat a nursing course only once. If the student does not
earn a grade of at least "C" upon repeating the course, the student cannot continue in the
School of Nursing. If, while repeating the course, the student drops the course or
withdraws from The University at a time when the student's performance in the course is
considered to be inferior to that required for a grade of "C", the student may not reenroll
in the course or continue in the School of Nursing.

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N365P Spring 2012

Religious Holidays: Regular attendance at all class meetings is expected. Instructors are
responsible for implementing attendance policy and must notify students of any special
attendance requirements.

A student who is absent from a class or examination for the observance of a religious
holy day may complete the work missed within a reasonable time after the absence, if
proper notice has been given. Notice must be given at least 14 days prior to the classes
scheduled on dates the student will be absent. For religious holy days that occur within
the first two weeks of the semester, notice should be given on the first day of the
semester. It must be personally delivered to the instructor and signed and dated by the
instructor, or sent certified mail, return receipt requested. A student who fails to complete
missed work within the time allowed will be subject to the normal academic penalties.

Special regulations of colleges and schools, required by the unique nature of their
programs of study, may be enacted through the normal legislative process and printed in
“The Undergraduate Catalog”. These special regulations may not conflict with University
regulations on class attendance and absence.

Student Conduct Policy: Students and faculty in the School of Nursing each have responsibility
for maintaining an appropriate learning environment. Faculty have the professional
responsibility to treat students with understanding, dignity and respect and to guide the
teaching/learning process. Students are expected to refrain from verbal and nonverbal
behaviors in the classroom and clinical that may be distracting to others, such as, but not
limited to: arriving late or leaving early, side conversations, text messaging, note passing,
surfing the internet or answering e-mail on laptops, and answering cell phone or pager.
Students who persistently engage in behaviors that are disruptive to the teaching/learning
process may be required to leave the setting. For further information refer to General
Information, Institutional Rules on Student Services and Activities, Chapter 11: Student
Discipline and Conduct.

The School of Nursing is a professional school and we often have members of the public
visiting our facility; therefore, we require students to dress in a professional manner at all
times. There is a very specific School of Nursing uniform policy for clinical settings and
within the School of Nursing building we can be a bit more relaxed; however, general
rules of dress still apply.
1. Body piercing, other than ears, must not be visible.
2. Revealing clothing must not be worn or, at a minimum, must be covered while in
the School of Nursing. Revealing clothing consists of:
i. midriff baring shirts
ii. short-shorts or short skirts
iii. low-rise pants &/or low cut shirts that reveal “cleavage”

Please remember that you are representing the School of Nursing and the nursing
profession. As such you are expected to maintain an appropriate level of professionalism
at all times.

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N365P Spring 2012

Medications Policy Statement:

a. As a requirement for clinical course progression (N325P, N355P, N365P, N366P and
N377P), each student must pass a medication calculation/conversion and abbreviation
test with a grade of at least 90% on each section, each semester.
b. Each student is expected to utilize assigned and recommended learning resources to
prepare for taking the test.
c. The medication test will be scheduled by the instructor at the beginning of each semester.
d. Calculators may be used for testing, but no programmable calculators are allowed. No
formulas, conversion tables, or personal data assistants (palm pilots, pocket PCs, or cell
phones) will be allowed.
e. If a score of 90% is not achieved on the first test, the student must meet with the
instructor to develop a learning contract.
f. The agreed upon learning activities in the contract must be completed prior to re-testing.
g. Re-testing will be scheduled by the instructor.
h. If a score of 90% is not achieved after the first re-test, additional learning activities and
testing will be required until competency is achieved.
i. Because accurate calculation of drugs is essential to patient safety, students will not be
allowed to give medications in clinical settings until the medication test has been
successfully passed.
j. Insufficient experience in medication administration in the clinical setting may affect the
achievement of clinical objectives and result in failure of the course.

Infectious Disease Policy: Students in all clinical courses are asked, but not required, to report
any infectious diseases they are carrying at the time of the clinical placement to
supervising faculty and the clinical agency. The purpose of this request is to give faculty
and agencies an opportunity to make reasonable accommodations for student, staff, and
patient needs. Acute illness must be reported promptly to your instructor.

Compliance Policy: All UT Austin School of Nursing students who are enrolled in clinical
courses at any time during the academic year must be fully compliant PRIOR to the first
class day or they will be dropped from their clinical course(s). The only students who are
exempt from this compliance policy are those who are enrolled in lecture-only courses
(e.g., PhD students). Students may petition to be re-enrolled in clinical course(s) only
after compliance is confirmed by the Student Affairs office. If the petition is approved,
students will be re-enrolled; however, students will not be guaranteed their preferred
clinical site or instructor. Students are responsible for maintaining their compliance
throughout the semester. Students must bring copies of their compliance information
(immunization records, CPR certification, compass training, and any agency-specific
training, etc.) to the Student Affairs office, NUR 2.104A, in order to update their record.
Please call the Student Affairs office at (512) 232-4780 with any questions about
compliance.

Students Transporting Clients in Their Personal Vehicles: Students are not permitted to transport
clients or family members of clients in their own or other vehicles at any time.
Malpractice liability insurance does not provide coverage should an accident or other

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N365P Spring 2012

untoward event occur while transporting a client. Students are encouraged to assist the
client to make transportation arrangements with family, friends, neighbors, volunteer
agencies, or public transportation resources.

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N365P Spring 2012

Scholastic Dishonesty Policy and Professional Integrity: Refer to the General Information for
information on the Scholastic Dishonesty Policy Sec. 11-802. Scholastic dishonesty
includes, but is not limited to cheating, plagiarism, collusion, falsifying academic records,
and misrepresenting facts. The Dean of Students Office records acts of dishonesty and
notifies the School of Nursing of each incident. In addition to all of the University
statements and policies relative to academic dishonesty, the School of Nursing recognizes
the strong link between honesty in academic work and professional integrity. Any act of
academic dishonesty, including fabrication of reports or records of interactions with
clients, is considered incompatible with ethical standards of nursing practice. The School
of Nursing does not admit students who have a record of violations to the professional
sequence. Students who engage in scholastic dishonesty may be subject to dismissal and
may jeopardize their eligibility for licensure as a registered nurse.

Academic and Program Accommodations for Students with Disabilities: Refer to the General
Information for information on Academic and Program Accommodations for Students
with Disabilities or contact the Services for Students with Disabilities office in the Office
of the Dean of Students at 471-6259. The School of Nursing works to ensure that students
who have disabilities have equal access to the University’s programs and services.

If you have any questions about services or accommodations for students with
disabilities, please talk with the faculty member, the Assistant Dean for Undergraduate
Programs, or the Assistant Dean for Student and Clinical Affairs or directly call the
Office of the Dean of Students, Services for Students with Disabilities, 471-6259.

Honor Code: The profession of nursing has a legacy of public respect and trust. We provide
specialized care for the health needs of individuals and the community with integrity,
honesty, compassion, and state of the art knowledge and skills. Learning and practicing
responsible and ethical professional behavior is a vital part of professional education. The
Institutional Rules on Student Services and Activities given in the General Information
Catalog (Chapter 11) and The University of Texas at Austin’s Honor Code apply to all
nursing students:

The core values of The University of Texas at Austin are learning, discovery, freedom,
leadership, individual opportunity, and responsibility. Each member of the University is
expected to uphold these values through integrity, honesty, trust, fairness, and respect
toward peers and community.

Additionally, the School of Nursing has its own honor code:

As a student in The University of Texas at Austin’s School of Nursing, I pledge myself to
be honest in all of my student activities including, but not limited to, all of my scholastic
work and interactions with patients, members of the community, faculty, and peers.
Furthermore, I will not use any substance prior to or during my interaction with patients
that could alter my judgment or ability to render safe care: this includes but is not limited
to any use of alcohol, illegal drugs, and prescription or over-the counter drugs that may
impair my mental and/or physical abilities required to perform safe patient care. I will
disclose to my instructor any violations of the above standards of conduct.

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N365P Spring 2012

Policy Related to Progression Within and Between Clinical Nursing Practicum Courses: Since
S1 students are enrolled in N365P (Maternity) and N366P (Pediatrics) simultaneously, if a
student fails one of these courses during the first half of the semester, she/he must proceed with
taking the other course during the second half of the semester and then must register the
following semester in order to retake the failed course.

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N365P Spring 2012

IN CASE OF EMERGENCY

IF YOU SEE SMOKE, SEE FLAMES, SMELL SOMETHING BURNING, OR BECOME

AWARE OF ANOTHER EMERGENCY THAT MAY REQUIRE EVACUATION OF THE
BUILDING, IMMEDIATELY:

1. If possible, ISOLATE the fire or other emergency by closing the door.

2. ACTIVATE the nearest FIRE ALARM PULL STATION.
3. EVACUATE to the PRIMARY or ALTERNATE ASSEMBLY AREA.
4. Dial University Police at 911 or Dispatch 471-4441.

DO NOT CALL 911 UNTIL YOU ARE OUTSIDE THE BUILDING.

IF A FIRE ALARM IS ACTIVATED:

• In a calm and orderly manner, proceed to evacuate the area and follow the instructions of the
Fire Wardens or emergency response personnel. Each floor has two designated wardens.
Their role is to ensure that everyone on their floor has proceeded to the fire exit stairs.
• Do not rush, push or panic.
• Close your office, classroom, or lab door behind you.
• EVACUATE to the designated ASSEMBLY AREAS. If your progress to the PRIMARY
assembly area is impeded, proceed to the ALTERNATE assembly area.
• DO NOT USE ELEVATORS TO EVACUATE. Descend the nearest fire exit stairs in single
file down to the GROUND LEVEL (first floor) and exit the building. Fire exit stairs are
located on the southwest and northwest ends of the building.
• If there is someone who requires assistance, please provide it.
• Do not reenter the building unless directed by UTPD or an Austin Fire Department Officer
in charge.

DO NOT BLOCK ACCESS TO BUILDING FOR EMERGENCY PERSONNEL. Do not exit

through the front door of the building unless you are in the lobby areas outside the central
elevators/stairwell. If you are in the courtyard outside the second floor lobby, you may exit
through the glass doors to the east or west, then out to one of the designated assembly areas.

ASSEMBLY AREAS:

From NORTHWEST FIRE STAIR EXIT—proceed to first floor stairwell exit door to outside of
building. DO NOT ENTER FIRST FLOOR HALLWAY AND EXIT THROUGH GLASS
DOORS. Primary assembly area is across the north bridge toward tennis courts. Alternate
assembly area is east end of F23 parking lot near Red River St.

From SOUTHWEST FIRE STAIR EXIT— proceed to first floor stairwell exit door to outside of
building. DO NOT ENTER FIRST FLOOR HALLWAY AND EXIT THROUGH GLASS
DOORS. Primary assembly area is south to Centennial Park. Alternate assembly area is across
south bridge toward tennis courts.

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N365P Spring 2012

to tennis courts

creek

to park

to lower level to lower level

patio

Red River

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Course Schedule A (First Half of Semester 1/17 to 3/6, 2012)

(*All reading is from the Lowdermilk, Perry, Cashion textbook unless otherwise noted.)

Date Time/Location Topics and Assignments

Tuesday 0830-0930 Course Orientation

Jan. 17
0945-1030 Video: Stages of Labor and Discussion
NUR 1.106
1045-1215 Birth-Related Procedures
p. 332, 351, 695-714, 311-312

1215-1300 Lunch

1300-1400 Coping and Relaxation in Labor

p. 284-313, 355-360

1415-1545 Newborn Feeding

p. 528-558

1600-1730 Perinatal Loss and Grief

p. 801-809

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N365P Spring 2012

Date Time/Location Topics and Assignments

Monday 0800-1100 Simulation Lab I (Momii and Heinze)
Jan. 23
NUR 2.104A Newborn Assessment
p. 457-473, 479-490

Labor Assessment
p. 336-382

Fetal Monitoring
p. 316-330

Postpartum
p. 383-391, 395-407

1100-1200 Lunch
NUR 2.104A
1200-1500 Simulation Lab II (Anderson)

Newborn Assessment
p. 457-473, 479-490

Labor Assessment
p. 336-382

Fetal Monitoring
p. 316-330

Postpartum
p. 383-391, 395-407

Tuesday 0900-1200 Skills Lab

Jan. 24 p. 503-504
NUR 2.104A
1200-1300 Lunch

1330-1430 Hospital Tour

Learning Center 3 Maternity On-line Tests due by 1700

Learning Center Medication Exam due by 1700

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N365P Spring 2012

Date Time/Location Topics and Assignments

January 27 Learning Center Remediate Maternity On-line Tests by 1700

Learning Center Make up for Medication Exam due by 1700

Monday First Clinical Day

January 30

Tuesday Last Clinical Day

March 6

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Course Schedule B (Second Half of Semester 3/19 to 5/1/12)

(*All reading is from the Lowdermilk, Perry, Cashion textbook unless otherwise noted.)

Date Time/Location Topics and Assignments

Monday 0900-1000 Course Orientation

3/19
NUR 1.108 1015-1100 Video: Stages of Labor and Discussion

1100-1200 Lunch

NUR 2.104A 1200-1500 Skills Lab

p. 503-504

1530-1630 Hospital Tour

Tuesday 0900-1015 Birth-Related Procedures

3/20 p. 332, 351, 695-714, 311-312
NUR 1.108
1030-1130 Coping and Relaxation in Labor
p. 284-313, 355-360

1130-1230 Lunch

1230-1400 Newborn Feeding

p. 528-558

1415-1545 Perinatal Loss and Grief

p. 801-809

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N365P Spring 2012

Date Time/Location Topics and Assignments

Monday 0800-1100 Simulation Group I (Momii & Walker)
3/26
NUR 2.104A Newborn Assessment
p. 457-473, 479-490

Labor Assessment
p. 336-382

Fetal Monitoring
p. 316-330

Postpartum
p. 383-391, 395-407

1100-1200 Lunch

1200-1500 Simulation Group II (Anderson)

Newborn Assessment
p. 457-473, 479-490

Labor Assessment
p. 336-382

Fetal Monitoring
p. 316-330

Postpartum/Parenting Assessment
p. 383-391, 395-407

Learning Center 3 On line Maternity Exams due by 1700

Tuesday First Clinical Day

3/27

Friday Learning Center Remediate Maternity On-line Tests by 1700

3/30

Tuesday Last Clinical Day

5/4

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N365P Spring 2012

Evaluation and Grading

Students are evaluated on their clinical performance and completion of their assignments.
Instructors use grading rubrics so that student assignments receive equivalent evaluations.
However, clinical sites and situations vary; therefore, anticipate differences between clinical
groups in the way assignments are to be completed. Each clinical instructor will determine
assignment requirements and due dates. Complete each assignment individually. Assignment
guidelines follow in this syllabus.

Course grade assignment is as follows:

A = 90 - 100
B = 80 - 89
C = 75 - 79
D = 65 - 74
F = Below 65

Grades will be determined as follows:

Assignments and Percent of Grade
Clinical Practicum & Online Tests ...................... 60%
Nursing Process Report 1 .................................... 15%
Nursing Process Report 2 ................................... 15%
Data Collection Sheet Without NPR ..................... 3%
Exemplar Patient Presentation ............................... 5%
Post Tests ............................................................... 2%

* Clinical assignments that are not turned in on the due date will be dropped one letter grade for
each day past due. Exceptions will be made only when the student has negotiated a new due
date with the clinical instructor prior to the due date.

Introductory Lecture/Clinical Series:

During the first three days of the course the instructors will present the basic concepts and
assessment techniques that are required for the nursing care of childbearing women and their
newborns. A combination of simulation and lecture will be utilized to present these concepts and
assessments.

Attendance is mandatory.

A post-test will be given at the end of each two-hour session. Attendance at each simulation
station provides full credit for that station. Cumulative performance on post-tests and simulation
attendance will account for 2% of your clinical grade. Lecture post-tests cannot be made up.
Students who fail to attend simulation will receive a 0 for each station missed. In the event of
exceptional circumstances, which make it impossible for a student to be present for simulation,
the instructor must be notified in advance. If the absence is excused, the student may make
arrangements with the instructor to take a quiz for each simulation station missed. These quizzes
will contain material from the assigned corresponding readings.

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N365P Spring 2012

Clinical Practicum:
Students will be assigned to a maternity unit where they will care for pregnant women, new
mothers, and newborns. Students will perform systematic assessments of their patient(s),
consider family and social support systems, identify the patient's actual and potential nursing
diagnoses, plan and provide nursing interventions for those diagnoses, and evaluate the
effectiveness of the interventions. Patient education is also an important part of mother-baby
care; therefore, education will be part of pre-discharge care and post-discharge planning.

Clinical Performance:
Criteria and guidelines for clinical performance are specified in the "Clinical Evaluation Tool"
(course syllabus). Clinical performance and study guides will count for 60% of your grade for
this course.

As indicated on the "Clinical Evaluation Tool," the following three criteria are considered
CRITICAL ELEMENTS in the student's evaluation. If the clinical instructor observes behaviors
which in his/her judgment indicate that the student is not meeting any one of these three criteria
at a passing level, the student will not receive a passing grade, regardless of the behaviors
assessed in the remainder of the evaluation tool.

1. Delivers nursing care that prevents real or potential personal harm to clients and their
families.
2. Demonstrates having a theoretical knowledge base necessary for clinical practice.
3. Demonstrates the use of communication skills necessary for patient safety.

Clinical Conference:
Each clinical group will have a weekly conference that may be scheduled at the hospital or
School of Nursing. The conference time is used as a discussion period to relate information
presented in N265 to the actual patients cared for by the students. Students are expected to bring
to the clinical conference examples of how they have applied concepts, theories and processes in
the clinical setting. The objectives for clinical conference include:

1. Utilize evidence-based practices to facilitate the nursing process

2. Discuss psychosocial and cultural issues affecting childbearing families
3. Apply clinical knowledge and critical thinking to common maternal/newborn
complications

Clinical Preparation/Online Tests:

In order to demonstrate clinical preparation necessary for providing safe nursing care, students
will be required to pass 3 online tests relevant to the areas they will be working in throughout
this clinical rotation: intrapartum, postpartum, and newborn. Each test will consist of
approximately 20 questions; a minimum passing score is 80%. Written study guides for each of
the 3 areas will be provided (posted on Blackboard) to students to aid in their preparation for the
online tests. The 3 Maternity On-Line tests are due by1700 on Tuesday, January 24 (1st Half)
and March 26 (2nd Half). If a student does not pass one or more of the tests, an additional
assignment will be required as determined by the clinical instructor.

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Exemplar Patient Presentation

Over the duration of this course, you will have the opportunity to work with a variety of patients
who are experiencing unique challenges in their lives. For this presentation, consider these
patients and select one that was an exemplar case for you (maternity/newborn). Exemplar cases
are those which stand out as powerful instances of experiential learning (Benner, 1984, From
Novice to Expert). Experience in exemplar cases results in a “turning around of preconceptions”.
Because learning is a very personal activity, the focus of the exemplar case resides with the
individual student’s identification of personal knowledge growth in some arena of nursing
practice.

Purpose: The purpose of this activity is for the student to synthesize a meaningful learning
experience and share this learning with faculty and peers.

Directions:

1. Select one maternity or newborn client who was cared for during clinical for presentation
to the clinical class of N365P.

2. Review clinical notes and synthesize the pertinent data for presentation.

3. Introduce the client case by sharing characteristic data such as age, race, marital status,
diagnosis, and any pertinent history that may have had an impact on the learning
experience.

4. Clearly identify what made this case a meaningful learning experience for you.

5. Describe how you foresee this exemplar experience changing or influencing your future
nursing care of clients.

6. Relate this case to current professional literature: research-based or clinical practice-

based literature (article should be no older than 5 years).

Grading: 5% of total grade

Adheres to 10-15 minute time limit.

Uses audiovisual materials appropriately.
Responds to audience questions thoughtfully.
Content reflects analysis of learning experience.
Literature cited was appropriate for presentation subject matter.

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Exemplar Patient Presentation (5% of Total Grade)

Grading Criteria

1. Was case exemplar? Was there experiential learning? (Novice to expert?)

2. Presentation was creative, presented in your own words (not read). Used learning tools
(i.e. posters, overheads, handouts, props, PowerPoint recommended).

3. Was precise, succinct; given within time frame? (10-15 min.)

4. Identified client demography, brief pathophysiology nursing diagnosis, nursing goals,

nursing interventions, rational for interventions, evaluation/re-evaluation.

5. Supporting literature/research (brief discussion).

Student Grade

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N365P Spring 2012

Nursing Process Reports:

Students will complete two Nursing Process Reports with accompanying data sheets and one
data collection sheet without the NPR.

NPR Instructions:
Choose your patient's highest priority problem (aka nursing diagnosis) to develop in detail. You
may choose to use a "high risk for" diagnosis, since many patients are not ill. State the patient’s
problem as actual or high risk….related to: (main etiological factor)…as evidenced by (AEB):
(data pertaining to signs/symptoms). If using a "risk for" diagnosis, you will not have the "AEB".
For each diagnosis, include the following:

Assessment
1. What are the defining characteristics (general signs and symptoms) that your patient is
having that prompted this diagnosis (mark with an asterisk which ones your patient has)?
If this is a "risk for" diagnosis, what symptoms would you look for?

2. What are the risk factors for this diagnosis (mark with an asterisk which ones your patient
has)? What is the related pathophysiology (i.e., why is your patient having this problem
or at risk for this problem? Be specific about your patient's circumstances.

3. List relevant assessment data. List actual patient behaviors, vital signs, lab results, etc.
Take into consideration this patient's specific condition and location of care (examples:
she is in active labor or newborn infant recently admitted to Newborn Nursery).

Planning
What are your overall goals for your patient? What are your objectives to meet these goals? They
should be measurable, realistic and appropriate for this patient’s specific condition. For
example: The patient will by (date/time) .

Implementation

What nursing interventions will you implement to help your patient achieve their goals? Please
use the first person to describe what you did (i.e., "(My nurse and) I did " or "I
would do ). Provide a reference (including page numbers) and rationale for
all orders, where applicable. Be sure to include patient and family education. After researching
the literature for your NPR, you may realize that there were more things you could/should have
done, but perhaps you did not know to do them, or didn't have the chance. Include these
interventions also with explanation for why they weren't done, and what you would do next time.

Evaluation
Assess your patient's response to each nursing intervention. Was it resolved, revised or to be
continued? If the intervention was not done, explain why.

21
N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Nursing Process Report Grading Rubric Points

Data Sheet 20

Assessment
Defining Characteristics
• Review the major and minor defining characteristics listed for the diagnosis in the textbook.
(Indicate by asterisk which ones apply to your patient.)
• List the assessment data (patient behaviors, lab results, etc.) to indicate whether the defining
characteristics (signs/symptoms) are present for this patient.

Related Factors
• State the main etiological factor and most pertinent contributing factors (include related 20
pathophysiology).
• Remember that high-risk problems do not have signs or symptoms, but have risk factors
instead.

Nursing Diagnosis Statement (3-part)

• State the patient problem as actual or high risk.
• …related to: (main etiological factor).
• …as evidenced by: (data pertaining to defining characteristics or signs/symptoms) - unless a
high risk diagnosis.

Planning: Overall Goal (State one overall goal for your patient)
Objectives and Target Dates (should be measurable, realistic, and appropriate)
The patient will: AEB
1. by (date). 20
2. "
3. "
(etc.)
Implementation
Nursing Orders (including rationale and reference with page number if taken from text.)
Nursing orders must be prioritized.
The nurse will: 20
1.
2.
3. etc.
Evaluation
A. Assess patient response to nursing orders that were implemented and revise orders if
indicated. If nursing orders not implemented, state reason.
20
B. State if objective is resolved, revised or to be continued. Include data (patient behaviors)
to support each judgment. If objective is to be continued, give date to reevaluate.
C. State if overall goal(s) was met.
Reference list (include scholarly reference list at end of process.)

22
N365P Spring 2012

Expected Behaviors for all Clinical Experiences:

The following behaviors are consistent with the role of a professional person and are expected of
nursing students. Also, please refer to Student Responsibilities outlined in the School of Nursing
Catalog.

The student will:

1. Report for clinical at the specified time. The shift starts at 6:45 a.m. or 2:45 p.m. If the
student is unable to attend or will arrive late, the instructor must be notified by phone (not
e-mail) prior to the scheduled starting time or as soon as possible when emergency
circumstances arise. If the instructor cannot be reached, the student must call the clinical
agency, leaving a message for the charge nurse and instructor.

2. Complete all assignments on the due date or make prior arrangements with the instructor.

3. Come to the clinical at a physical and mental level that will not jeopardize the care given
to the client and that will promote own learning.

4. Come to the clinical with the knowledge/skills necessary to meet the objectives of the
day's experience. If not adequately prepared, the instructor reserves the right to send the
student home.

5. Follow general student uniform policies: Please refer to the Undergraduate Student
Manual or website http://www.utexas.edu/nursing/html/courses.html

6. Always identify yourself and your purpose to the person in charge whenever appearing in
an agency if you are not with the instructor.

7. Promote client safety and well-being and minimize liability of the student and the
instructor in the following ways:

a. Place the needs of the client above the need to complete an

assessment/assignment should a conflict arise.

b. Keep client information confidential. Do not use names on notations made about
clients or on written assignments for your clinical experience. Also, do not use
doctors' names, patient medical record numbers, or account numbers. Use initials
only. Do not leave notes about an identifiable client anywhere where
nonprofessional individuals may read them. Per hospital policy, do not copy
patient records (ex. laboratory or radiology reports).

c. Refrain from contradicting information given to a client by other health team

members until the problem can be discussed with the instructor and/or that health
team member.

23
N365P Spring 2012

d. Give patient care only when the instructor is in the agency.

e. Give patient care, including administering medications and treatment, with

supervision. ‘With supervision’ means having conferred or consulted with the
instructor and receiving permission to proceed independently.

f. Do not take verbal or phone orders from a physician.

g. Give a verbal report regarding your patient(s) to the appropriate agency nurse
when leaving the unit and/or as the patient's condition warrants it.

h. Document accurate and appropriate information regarding your assigned

patient(s) to indicate nursing care and patient progress and to assure continuity of
communication.

8. Give prescribed medications for your patient(s) on time. When giving any medication,
you need to know the trade and generic names, classification, purpose for which it is
given, main action of drug, side effects, usual dosage, contraindications, and nursing
implications. You are not allowed to give any medication without this basic information.

a. The instructor and/or clinical teaching assistant must be present as you prepare
and administer the medication at all times unless you are instructed otherwise.

b. The instructor will be present whenever you give an injection and when you
administer a drug intravenously. If the instructor cannot be with you, ask the
appropriate staff RN to give the medication.

c. Double checking of anticoagulants and insulin is standard procedure in most

hospitals. Clarify the procedure in the hospital where you are assigned.

d. Prior to giving a prn by any route, let the instructor know of your intent to do so.
If the instructor is not on the unit, page her.

* Medication supervision may be delegated to the clinical teaching assistant.

9. Demonstrate responsibility for fulfilling clinical behaviors by assessing own

understanding and skills, seeking clarification when in doubt, proceeding to complete the
assignments, and assuming responsibility for tasks undertaken.

24
N365P
The University of Texas at Austin
N365P Nursing Care of Childbearing Families Practicum
Guidelines for Childrearing Grade Determination
Criteria The “A” Student – Performs
in a consistently outstanding
manner in all areas
Nursing actions are performed
Competence
in a consistently well-
Technical
organized fashion; correctly
applies nursing principles to
all skills
Applies scientific and nursing
knowledge consistently as the
basis for meeting the needs of
Application of Knowledge
the client/family; is creative,
flexible and independent in
identifying and testing out
alternatives, approaches,
teaching methods, motivating
factors; identifies questions or
issues that need investigation
and plans corrective action;
consistently reviews
community resources for
client/family's long term needs
School of Nursing
Spring 2012
The “B” Student - Gives
quality nursing care;
performance is consistently
good
Nursing actions are carried out
in a safe and organized
manner; nursing principles are
applied to most skills
performed
Scientific and nursing
knowledge is utilized in
planning and implementing
nursing care most of the time;
is generally flexible; identifies
questions/issues that need
investigation, needs assistance
in planning corrective action;
shows less preference for
investigation of complex
problems; aware of
community resources;
connects clients as able
25
The “C” Student -
Consistently performs in a
safe manner
Level of performance is
inconsistent; may apply self
when particularly interested -
pay less attention in other
areas; nursing principles
applied to some skills
Needs assistance in applying
scientific and nursing
knowledge for planning and
providing nursing care; does
not demonstrate much
flexibility in meeting the
client and family needs; shows
a preference for investigation
of simple problems;
retrospectfully aware of
community resources
Spring 2012
The “D” Student - Performs
inconsistently and frequently
in an unsafe manner
Cannot perform nursing skills
safely; repeats previous
errors/mistakes; unable to
apply nursing principles to
skills
Does not utilize knowledge
when providing nursing care;
unable to make decisions
appropriate to specific client
needs; can’t identify simple
problems; neglects importance
of community resources to
discharge
N365P
Criteria “A” Student
Is highly self-directed;
seeks and uses a variety of
resources effectively to
improve nursing care and
extend own learning; uses
supervision to evaluate,
reinforce and extend own
Accountability
ideas; ongoing self-
evaluation is an inherent
part of the student’s work;
identifies specific areas of
strength as well as areas
needing personal growth
and learning; able to take
risks, allows self to fail;
identifies possible reasons
for failure, tries again
Is well-organized, sets
appropriate priorities based
on expressed client and
family needs and on own
Management
assessment of needs and
resources; can clearly
define reasons (or lack of
reasons) for priorities;
assumes the role of patient
advocate to enhance the
quality of nursing care
“B” Student
Demonstrates self-direction
and growth; is willing to
test out new ideas and
approaches with some
encouragement; uses
supervision for guidance
and to check out ideas;
generally open to new
ideas and moves on them;
usually is aware of the
need for and purposes of
supervision; able and
willing to evaluate self;
may need to identify
strengths and limitations
Is organized and sets
appropriate priorities with
some direction; is thorough
with most clients and
families; acts as a patient
advocate in managing
patient care
26
“C” Student
Takes little initiative for own
learning; waits to be told
what student role is and what
to do; generally uses
supervision for direction
rather than guidance; little or
unrealistic self-evaluation;
gives only partial
consideration to the
significant implications and
consequences of own actions
Needs assistance with work
organization, priority setting,
planning and implementing
care; often becomes bogged
down with extraneous
details; serves as patient
advocate when directed by
others
Spring 2012
“D” Student
Doesn’t seek situations to
meet own learning needs;
little preparation for client
care; frequently doesn’t seek
guidance when in doubt; fails
to follow suggestions for
improvement; generally
unaware of the significance
of own actions; unable to
utilize or accept constructive
criticism
Needs assistance daily with
work organization, priority
setting, planning and
implementing care; unable to
plan client care; unable to
identify situations in which
to serve as a patient advocate
N365P Spring 2012

Criteria “A” Student “B” Student “C” Student “D” Student

Explores and collects pertinent
and comprehensive data prior to
decision-making; withholds
early judgments, is continually
open to new data and revises
plans; written work is neat,
Nursing Process
Collects facts and May make decision without Cannot provide therapeutic
pertinent data; makes collecting adequate nursing care without assistance
decisions based on information; needs some and supervision; concentrates
collected information; assistance in determining what on one aspect of client care
more conventional is “adequate information”; without addressing others;
approach and care plans written work lacks depth; decisions which are made are

comprehensive, clearly stated,
organized and logical; gives
evidence of independent and
creative thinking; shows
movement from broad
generalities to specifics -
inferences, assumptions, etc.;
individualizes nursing
interactions - direct care,
counseling and teaching on basis
of client and family needs
than creative; written shows little or no independent
work is clear, organized thinking; may include broad
and logical; selects generalizations without logical
pertinent material; background; has difficulty in
evidence of thought and moving from generalizations to
independent thinking; specifics; nursing interventions
provides safe nursing are often based upon an
care with consideration assessment which lacks scope,
for comfort to the client insight and comprehensiveness;
and family tends to see and work with the
obvious and immediate needs
questionable in their therapeutic
effectiveness and/or logic;
written work shows little
understanding of cause/effect
relationships; cannot function
therapeutically without
assistance

Recognizes subtle clues to
relationships and behaviors; is
perceptive to overt and covert
needs of clients and families,
Interpersonal Skills &
Is perceptive to overt Relationship with clients and Unable to establish working
and some covert needs families, peers, co-workers and relationships with clients,
of clients and family, instructors are variable; has families, peers or instructor;
peers, and co-workers; some self-awareness; needs lacks insight into own behavior;

peers and co-workers; is self- with a little direction is assistance in looking at own unaware of clients’’ and
Communication

aware; can identify own attitudes
and values as they fit in or
conflict with others; aware of the
effect of self on others.
Developmentally appropriate
with children and families.
able to recognize subtle values and attitudes in relation families’ response to student’s
clues to relationship to those of clients and families; behavior or methods of
and behavior; is self- may lack insight into the effects communication
aware; is willing to of own behavior on others
look at own values and
attitudes in relation to
those of clients and
families; may not
always recognize effect
of self on others

27
N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Student Data Sheet

1. Name:

2. E-mail:

3. Phone Number(s):

4. Degree(s) held in other areas:

5. Types of skills, experiences, and background that you are bringing to clinical setting
other than those learned in nursing courses:

6. Do you speak any languages other than English?

7. Do you work? Part-time or full-time? In an area related to nursing?

8. Health or other information that needs to be shared:

28
N365P Spring 2012

Clinical Objectives for Care of the Family During the Postpartum Period

Provide nursing care in a family-centered manner that promotes healthy family interactions.
1. Assess the postpartum family using a systematic approach.
2. Develop a plan of care incorporating patient and family needs that maintains and
promotes general well being of the healthy mother, father (or significant other) and
infant.

3. Implement a nursing plan for a postpartum client (vaginal delivery and C-section) based
on the assessment data and including:
a. comfort measures (hot or cold packs, tuck pads, breast support, topical
medications)
b. administration of p.o. and parenteral medications
c. elimination procedures (catheterization, enema, rectal suppository)
d. promotion of positive parenting
- assist parents in eliciting responsiveness from infant
- assist parents in assessing uniqueness of infant
- assist mother with breastfeeding
e. preparation for discharge
- teaching needs re: care of infant
- holding
- feeding
- burping
- bathing
- care of umbilicus
- care of circumcision
- teaching needs re: mother
- breasts
- lochia
- episiotomy/lacerations
- elimination - urinary, bowel
- hemorrhoids
- exercise
- diet
- pregnancy planning
4. Manage the care of two postpartum patients during one clinical lab period.
5. Demonstrate effective use of interpersonal skills with patients, families and staff.
6. Evaluate the plan of care for specific postpartum patients.

7. Compare and contrast the care of a mother having a C-section birth with a mother having
a vaginal birth.

29
N365P Spring 2012

Postpartum Audiovisual References

Title Format Call Number Year Time

Nursing Assessment of the Postpartum Video WQ 500 N974 1990 22 min.

Patient
Hospital to Home. Discharge Planning Video WQ 500 H828 2002 36 min.
Bundle of Blues, Postpartum Depression DVD WQ 500 B842 2005 13 min.
Postpartum From Pregnant to Parent DVD WQ 500 P857 2006 36 min.

Additional Resources for the Care of Childbearing Families

Perinatal Nursing Education. Booklets. WQ 200 P445. March of Dimes 2008

Perinatal Care of the High-Risk Woman
• Care of the Multiple-Birth Family
• Challenges and Management of Infertility
• Diabetes in Pregnancy
• Embryonic and Fetal Evaluation During Pregnancy
• Genetic Issues for Perinatal Nurses
• Hemodynamic Monitoring of the Critically Ill Obstetric Patient
• High-Risk Antepartal Home Care
• Obstetrical Emergencies for the Perinatal Nurse
• Preterm Labor: Prevention and Nursing Management
• Sexually Transmitted Infections, Including HIV

Psychosocial Issues
• Abuse During Pregnancy
• Cultural Competence in the Care of Childbearing Families41
•
• Loss and Grieving in Pregnancy and the First Year of Life
• Perinatal and Neonatal Ethics
• Pregnancy: Psychosocial Perspectives
• Tobacco, Alcohol and Drug Use in Childbearing Families

Pregnancy. Conception to Neonate Pregnancy. Video. WQ 200 P923 Prog 1. 1992. 26 min.
Pregnancy. Reducing Risk Factors. Video. WQ 200 P923 Prog 3. 1992. 34 min.

30
N365P Spring 2012

POSTPARTUM DATA SHEET

Student Date(s) of Care

Delivery Method Date/Time of Birth

I. ASSESSMENT: DATA COLLECTION-HISTORY

Pts initials Significant Family Medical History:

Age Allergies
Race/Ethnic Group
Blood Type and Rh Labor and Birth: (Mother)
Maternity History AROM ___ SROM ___
Gravida Para Prolonged ROM (>18 hours) _______
T (Term) P (Premature)
A LC Labor: Spontaneous
Induced _____ Reason____________________
Past Obstetrical History: Augmented _______Reason________________

Year Sex Weight Complications Vaginal: Spontaneous__________

Forceps _______ Vacuum ________
Intact perineum Yes ___ No ____
Episiotomy (type) repair
Laceration (degree) repair

C/S: Reason
This Pregnancy: Gestational age @ delivery Scheduled Unscheduled
Gestation week when prenatal care begun:
Anesthesia: Local ___ Epidural ___Spinal ____
Complications/problems during this pregnancy General _____ None _____

Medications During Labor (drug/dosage):

Childbirth preparation (may include classes on early Social Support: (Include formal or common law
pregnancy, birthing process, breastfeeding, etc.) marital status, household members, significant
others)

Prenatal Care Provider: If the father of the baby is not living with the mother,
Private (physician's initials): to what extent is he involved?
or Clinic (Initials)
Initials and ages of siblings:
_____

Personal Medical History: Infant Data: Weight Sex

APGAR 1 min ______ 5 min ______
Newborn nursery NICU
Type of feeding: Breast _____ Bottle ________

31
N365P Spring 2012

Length of labor: (Applies to both vaginal delivery and unscheduled C-section)

Time began Time ended Hours Minutes

Stage I
Stage II
Stage III

Total Hours in Labor

If scheduled C-section:
Delivery of infant @ Delivery of placenta @ To PACU @
Estimated blood loss (EBL)
Complications (maternal or fetal) of this birth

Who attended birth with mother (besides staff)?

Mother's stated impression about labor and birth experience:

Mother/father/significant others' stated perceptions and observed response to infant:

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

PHYSICIAN ORDERS: (current postpartum orders at time of data collection)

IVs:
Scheduled meds: (name of drug, dosage, classification, and administration times)

PRN meds: (name of drug, dosage, classification)

32
N365P Spring 2012

POSTPARTUM DATA SHEET

ASSESSMENT (cont'd.)

POSTPARTUM ORDERS CONTINUED:

Diet, activity, dressing change, treatments, etc.

DATA COLLECTION-LAB TESTS: Please include a printout or write down all lab values
(per hospital's policy). Include pre- and post-delivery lab data (CBC before and after birth, T&S,
RPR, HIV, HBSAG, etc.). Highlight abnormal labs and indicate probable reason. Submit
explanations and source used on separate page.

TEST DATE/TIME AGENCY CLIENT RATIONALE

VALUE VALUE

33
N365P Spring 2012

POSTPARTUM DATA SHEET

ASSESSMENT (cont'd.)
ASSESSMENT - Physical Exam

VS
IV (if present)
Lungs
CV (pulses, Homan's, edema, cardiac)
GI/GU
Breasts/Nipples
Incision (if present)
Uterus/Lochia
Perineum/Hemorrhoids

Nursing Diagnoses - (list in order of importance) (Diagnoses must include three part
statement unless high risk DX.)
1.

2.

3.

4.

5.

34
N365P Spring 2012

Clinical Objectives for Care of the Family During the Intrapartum Period

Objective: Provide nursing care in a family-centered manner that promotes healthy family
interactions.

1. Obtain the history and admission information from patient being admitted to the labor
and delivery unit.

2. Assess assigned intrapartum family, including:

a. type of childbirth preparation, if any

b. family's objectives for birth experience
c. uterine contractions (frequency, duration, intensity)
d. fetal heart rate (baseline, accelerations, deceleration, and variability)
e. behaviors indicative of latent, active and transitional phases of first stage of labor
f. psychological response to labor and birth

3. Develop a plan of care, incorporating patient and family needs, that maintains and
promotes the general well-being of the family throughout each stage of labor and
delivery.

4. Provide appropriate nursing interventions for healthy intrapartum patients and families:

a. support and comfort measures

b. catheterization
c. abdominal shave prep
d. administration of p. o. and parenteral medications
e. venipuncture
f. set up and regulate IV solutions (with exception of Pitocin)
g. attach external fetal monitor
h. monitor maternal blood pressure, temperature, pulse, and respiration
i. obtain and/or assist with lab specimens
j. assist with special procedures such as
- amniotomy
- ultrasound/biophysical profile
- non-stress test
- stress test
k. assist coach in performance of support measures as appropriate

5. Report deviations from normal immediately to primary nurse or instructor and provide
appropriate nursing actions for:

a. fetal bradycardia or tachycardia

b. decelerations
c. uterine tachysystole
d. increase or decrease in vital signs of mother

35
N365P Spring 2012

e. difficulty in coping
f. unusual bleeding

6. Correctly position patient prior to epidural anesthetic. Provide appropriate nursing care
prior to, during and following administration of epidural anesthesia.

7. Assist in the preparation of a family having a Cesarean birth.

8. Assess parents' response to their newborn immediately following the birth.

9. Perform APGAR at 1 and 5 minutes; validate results with RN or instructor.

10. Implement a plan of care for a family in the fourth stage of labor, focusing on:

a. monitoring of vital signs

b. palpation and massage of fundus
c. evaluation of lochia flow and episiotomy/perineum
d. palpation of urinary bladder and prevention of distention
e. fluid and nutritional needs
f. comfort measures
g. facilitating parent-infant interaction
h. facilitating breastfeeding
i. facilitating sibling-infant interaction when appropriate

11. Evaluate plan of care for assigned intrapartum families.

Labor and Delivery Audiovisual References

Title Format Call Number Year Time

Labor and Delivery for Teens Video WQ 150 L123 1996 28 min
Healthy Steps for Teen Parents. Prenatal Care Video WQ 150 H434 Prog 1 2003 25 min
Healthy Steps for Teen Parents. Labor and Video WQ 150 H434 Prog 2 2003 25 min
Delivery
Gentle Birth Choices Video WQ 150 G338 1996 47 min
Giving Birth: Challenges and Choices Video WQ 150 G539 1998 35 min

Comfort Measures for Childbirth Video WQ 150 C732 1995 42 min

Pregnancy Labor and Delivery DVD WQ 200 L122 2004
Prog 1: Pregnancy
Prog 2: Labor and Delivery
Prog 3: Pain Control
Prog 4: Leopold’s Maneuvers.
Stages of Labor (2nd ed.) Video WQ 300 S7787 2006 28 min
Just in Case. Cesarean Video WQ 430 J96 1996 25 min

36
N365P Spring 2012

LABOR AND BIRTH DATA SHEET

Student Date of Care
Delivery Method Date/Time of Birth

I. ASSESSMENT: DATA COLLECTION-HISTORY

Pts initials Prenatal Care Provider:

Age Allergies Private (physician's initials):
Race/Ethnic group or Clinic (initials)
Blood type and Rh Social Support: (Include formal or common law
Maternity History marital status, household members, significant others)
Gravida______________ Para ___________
T (Term) _____ P (Premature) ____ A ____ LC ____

Current pregnancy: LNMP Personal Medical and Surgical History:

Gestation week when prenatal care begun:

EDC
Dating Criteria Significant Family History:

Complications/problems during this pregnancy

Admission Data: Date
Time Reason
FHR Scheduled Procedures
Medications taken during current pregnancy Contractions:
Time of onset
Freq., duration, intensity on admission
Total weight gain
Childbirth preparation (may include classes on early Membranes on admission: Intact
pregnancy, birthing process, breastfeeding, etc.) Ruptured (date/time)
Fluid: clear meconium
odor odorless

Past obstetrical history: Initial Vaginal Exam: Date & Time

Year Gest. Total Hours Complications Delivery Dilation Eff. Station
of Labor Method Other information:

Last intake of food/fluid

Last slept

Anesthesia
(if applicable)

Medications administered during labor with explanation

Comments: of why medication was administered

37
N365P Spring 2012

LABOR AND BIRTH DATA SHEET

DATA COLLECTION: LAB TESTS

1) Prenatal labs: (found on prenatal record; most lab tests done on first visit).
Test Date(s) Results
Rubella
Antibody Screen
Diabetes Screen; GTT
Hct./Hgb.
RPR/VDRL
G.C.
Chlamydia
Hep B Surface Antigen
Sickle Cell
T.B. Screen
Herpes
Pap Smear
Group B Strep
HIV
MSAFP or MMS or TAST or
Nuchal Translucency
Other

Amniocentesis/CVS: Reason:
Ultrasound results and reason for ultrasound:
NST (number, reason):
Other lab tests:

2) Lab tests done during labor: include routine and any additional lab work. Please include a printout
or write out all lab. State rationale for labs ordered.

Test Reason Ordered Time Results

Explain all abnormal prenatal or intrapartal lab results: Cite author, title and page number of reference.

PHYSICIAN ORDERS: (Include orders for activity, monitoring, p.o. intake, IV fluids, medications, and
medical procedures during labor or pre-op care of c-section.)

38
N365P Spring 2012

DATA COLLECTION –– LABOR

Introduction: Include pertinent information about the patient and family not asked for on Data Sheet or
that data that requires further explanation. (Use the following as a guide.)

Labor:

Stage I began _______________ (Time/Date); ended ______________________ (Time/Date)

Describe the pt.'s behavior and nursing and medical interventions during the latent, active and transition
phases. Include baseline V.S. with deviations (explain probable reason for deviations), FHR (specify
mode of assessing), contraction pattern (frequency, duration, intensity), pt.'s and coach's activity,
relaxation and breathing techniques, comfort measures, medications, epidural, (patient's response,
including BP, pulse, FHR characteristics), vag. exams, personality changes, IV, use of Pitocin (induction
or augmentation), urinary output, emesis. If patient has a c-section, report nursing interventions
performed, including preop teaching.

Stage II began at ___________________ AM/PM; ended at _____________________ AM/PM

Describe pt.'s response to pushing including positions used, V.S., FHR, vag. exams, anesthesia, forceps,
pt. & coach's participation and reactions, personality changes, shave prep, time of delivery, sex of infant.
If patient has a c-section, report type of incision, anesthesia and events in Delivery Room.

Stage III began at __________________ AM/PM; ended at ______________________ AM/PM

Describe baby's response (Apgar & physical assessment), pt. and coach's reaction and their interaction
with the baby, time of placenta delivery, amount of Pitocin added to IV, condition of fundus, and amount
of vaginal bleeding.

Stage IV began at _________________ AM/PM

Describe pt.'s reaction during recovery. Include V.S., condition of fundus, amount of lochia, condition of
perineum or surgical dressing, epidural status (if applicable), bladder, reaction of mother & coach,
parent/infant interaction.

Total hours labor = _______________

NURSING DIAGNOSES (list in order of importance) (Diagnoses must be fully written out including
three part statement unless high risk DX.)
1.

2.

3.

4.

5.

39
N365P Spring 2012

Clinical Objectives for Care of the Newborn

Objective: Provide nursing care for a newborn infant in a manner that promotes healthy family
interactions.

1. Ensure patency of newborn's airway by positioning, postural drainage and correct

utilization of bulb syringe when necessary.

2. Provide safe newborn care (positioning, holding and transferring, bathing, diapering,
umbilical cord care, circumcision care, maintaining body warmth, breastfeeding, correct
formula if bottle feeding).

3. Verify the identity of an infant before initiating procedures; verify the identity of parents
before leaving an infant in mother's room.

4. Report deviations from normal immediately to primary nurse or instructor.

5. Record appropriate information regarding the status of the newborn (i.e. vital signs,
feedings, stools, urination and any deviations from normal.)

6. Perform a systematic physical assessment on a normal newborn, including:

- general measurements (vital signs, head & chest measurements)
- general appearance
- head-to-toe assessment
- assessment of clinical gestational age
- behavioral assessment (sleep/wake states)

7. Record findings of the physical exam accurately and concisely, using appropriate
terminology.

8. Assist parents in identifying infant states, behavioral cues and in knowing how and when
to interact with infant.

9. Prepare parents for care of infant at home by identifying their teaching needs and
implementing such.

Note: These objectives can be achieved in more than one setting, i.e. in the LDR Room,
Birthing Center, Postpartum Room or Newborn Nursery.

40
N365P Spring 2012

Care of the Newborn Audiovisual References

Title Format Call Number Year Time

Nutrition of the Infant Series Video WS 120 N976 2003

Prog 1. Diet During Pregnancy. 24 min.
Prog 2. Benefits of Breastfeeding. 24 min.
Prog 3. Techniques for Successful
Breastfeeding. 29 min.
Prog 4. Formula Feeding. 24 min.

Helping a Mother to Breastfeed Video 1990 20 min

Breastfeeding Kit—video, flipchart, mini breast Kit WS 125 B828 1997
pump, parent guides
Helping Parents Understand Their Newborn Video WS 105 H483 2003 35 min
Neonatal Behavioral Assessment Scale Video WS 105 N438 1999 22 min
Newborn Infant Care Video WS 113 N533 1998
The First Years Last Forever Video WS 113 F527 28 min
Nursing Care of the New Family: Infant Care Video WS 113 K73 1991 30 min
Touchpoints. Brazelton, T. Berry Video WS 113 1997
Vol 1. Pregnancy, birth & the first weeks T7227
Vol 2. The first month through the first year
Vol 3. One year through toddlerhood

Lamaze: You and Your Baby: Infant Care DVD WS 113 Y67 2004
Psychosocial Care. Infants and Toddlers Video WS 105 P371 1995 31 min
Smarter Than You Think Video WS 420 S636 19 min
Physical Assessment of the Normal Newborn Video WS 420 1986 34 min
P5778
The Infant Patient Encounter, Infant Exam CD WS 420 I43 2006

41
N365P Spring 2012

NEWBORN DATA SHEET

Student Date of Care

Baby's Initials Mother's Initials Gestational Age

Feeding Method Delivery Method: SVD C-Section

BIRTH DATA
Date & Time of Birth Blood type/Rh
APGAR / Coombs Test
Sex Mom’s Blood Type
Weight ______ lb. _____ oz / ______ gm
Length ______ inches / _______ cm
Head Circumference _________
Blood glucose (AccuCheck) __________ Time of Test __________
(if applicable)

SIGNIFICANT HISTORY OF MOTHER

Age _____ Gravida ____ Para ______ Term ___ Premature ___ A ___ LC ___ EDC ________

Prenatal: (Describe any health problems or exposure to detrimental environmental factors by

mother)

Intrapartum: (Include type of birth, total length of labor, medications, or anesthesia received
during labor, date, time and color of rupture of amniotic fluid, support system during labor and
birth, any problems during labor or birth.)

INTERACTION OF FAMILY WITH INFANT (describe observations):

42
N365P Spring 2012

PHYSICAL EXAMINATION OF INFANT

Date & time performed

Vital signs: T __________ P __________ R __________

General appearance (Include muscle tone and state of arousal in description.):

Note: For each of the following areas of assessment, describe normal characteristics noted in
infant and any variations or deviations from normal. ("Normal," "WNL” or "Normal
Configuration" are not acceptable descriptions).

Skin:

Head:

Face:

Eyes:

Ears:

Nose:

Mouth and Throat:

43
N365P Spring 2012

Neck:

Chest/Respirations:

Heart:

Abdomen:

Genitalia:

Anus and rectum:

Extremities:

Spine:

44
N365P Spring 2012

Reflexes Present Abnormal

Moro ______ _______
Palmar ______ _______
Plantar ______ _______
Sucking ______ _______
Rooting ______ _______
Swallowing ______ _______
Babinski ______ _______
Stepping (dance) ______ _______
Trunk incurvation ______ _______

Gestational Age: Date performed Determination weeks

SUMMARY OF ASSESSMENT FINDINGS: (Write out summary)

NURSING DIAGNOSES: (Diagnoses must be fully written out including three part
statement unless high risk DX.)

1.

2.

3.

4.

5.

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012

Student Data Sheet

1. Name:

2. E-mail:

3. Phone Number(s):

4. Degree(s) held in other areas:

5. Types of skills, experiences, and background that you are bringing to clinical setting
other than those learned in nursing courses:

6. Do you speak any languages other than English?

7. Do you work? Part-time or full-time? In an area related to nursing?

8. Health or other information that needs to be shared:

28
N365P Spring 2012

Clinical Objectives for Care of the Family During the Postpartum Period

Provide nursing care in a family-centered manner that promotes healthy family interactions.
1. Assess the postpartum family using a systematic approach.
2. Develop a plan of care incorporating patient and family needs that maintains and
promotes general well being of the healthy mother, father (or significant other) and
infant.

3. Implement a nursing plan for a postpartum client (vaginal delivery and C-section) based
on the assessment data and including:
a. comfort measures (hot or cold packs, tuck pads, breast support, topical
medications)
b. administration of p.o. and parenteral medications
c. elimination procedures (catheterization, enema, rectal suppository)
d. promotion of positive parenting
- assist parents in eliciting responsiveness from infant
- assist parents in assessing uniqueness of infant
- assist mother with breastfeeding
e. preparation for discharge
- teaching needs re: care of infant
- holding
- feeding
- burping
- bathing
- care of umbilicus
- care of circumcision
- teaching needs re: mother
- breasts
- lochia
- episiotomy/lacerations
- elimination - urinary, bowel
- hemorrhoids
- exercise
- diet
- pregnancy planning
4. Manage the care of two postpartum patients during one clinical lab period.
5. Demonstrate effective use of interpersonal skills with patients, families and staff.
6. Evaluate the plan of care for specific postpartum patients.

7. Compare and contrast the care of a mother having a C-section birth with a mother having
a vaginal birth.

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N365P Spring 2012

Postpartum Audiovisual References

Title Format Call Number Year Time

Nursing Assessment of the Postpartum Video WQ 500 N974 1990 22 min.

Patient
Hospital to Home. Discharge Planning Video WQ 500 H828 2002 36 min.
Bundle of Blues, Postpartum Depression DVD WQ 500 B842 2005 13 min.
Postpartum From Pregnant to Parent DVD WQ 500 P857 2006 36 min.

Additional Resources for the Care of Childbearing Families

Perinatal Nursing Education. Booklets. WQ 200 P445. March of Dimes 2008

Perinatal Care of the High-Risk Woman
• Care of the Multiple-Birth Family
• Challenges and Management of Infertility
• Diabetes in Pregnancy
• Embryonic and Fetal Evaluation During Pregnancy
• Genetic Issues for Perinatal Nurses
• Hemodynamic Monitoring of the Critically Ill Obstetric Patient
• High-Risk Antepartal Home Care
• Obstetrical Emergencies for the Perinatal Nurse
• Preterm Labor: Prevention and Nursing Management
• Sexually Transmitted Infections, Including HIV

Psychosocial Issues
• Abuse During Pregnancy
• Cultural Competence in the Care of Childbearing Families41
•
• Loss and Grieving in Pregnancy and the First Year of Life
• Perinatal and Neonatal Ethics
• Pregnancy: Psychosocial Perspectives
• Tobacco, Alcohol and Drug Use in Childbearing Families

Pregnancy. Conception to Neonate Pregnancy. Video. WQ 200 P923 Prog 1. 1992. 26 min.
Pregnancy. Reducing Risk Factors. Video. WQ 200 P923 Prog 3. 1992. 34 min.

30
N365P Spring 2012

POSTPARTUM DATA SHEET

Student Date(s) of Care

Delivery Method Date/Time of Birth

I. ASSESSMENT: DATA COLLECTION-HISTORY

Pts initials Significant Family Medical History:

Age Allergies
Race/Ethnic Group
Blood Type and Rh Labor and Birth: (Mother)
Maternity History AROM ___ SROM ___
Gravida Para Prolonged ROM (>18 hours) _______
T (Term) P (Premature)
A LC Labor: Spontaneous
Induced _____ Reason____________________
Past Obstetrical History: Augmented _______Reason________________

Year Sex Weight Complications Vaginal: Spontaneous__________

Forceps _______ Vacuum ________
Intact perineum Yes ___ No ____
Episiotomy (type) repair
Laceration (degree) repair

C/S: Reason
This Pregnancy: Gestational age @ delivery Scheduled Unscheduled
Gestation week when prenatal care begun:
Anesthesia: Local ___ Epidural ___Spinal ____
Complications/problems during this pregnancy General _____ None _____

Medications During Labor (drug/dosage):

Childbirth preparation (may include classes on early Social Support: (Include formal or common law
pregnancy, birthing process, breastfeeding, etc.) marital status, household members, significant
others)

Prenatal Care Provider: If the father of the baby is not living with the mother,
Private (physician's initials): to what extent is he involved?
or Clinic (Initials)
Initials and ages of siblings:
_____

Personal Medical History: Infant Data: Weight Sex

APGAR 1 min ______ 5 min ______
Newborn nursery NICU
Type of feeding: Breast _____ Bottle ________

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N365P Spring 2012

Length of labor: (Applies to both vaginal delivery and unscheduled C-section)

Time began Time ended Hours Minutes

Stage I
Stage II
Stage III

Total Hours in Labor

If scheduled C-section:
Delivery of infant @ Delivery of placenta @ To PACU @
Estimated blood loss (EBL)
Complications (maternal or fetal) of this birth

Who attended birth with mother (besides staff)?

Mother's stated impression about labor and birth experience:

Mother/father/significant others' stated perceptions and observed response to infant:

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

PHYSICIAN ORDERS: (current postpartum orders at time of data collection)

IVs:
Scheduled meds: (name of drug, dosage, classification, and administration times)

PRN meds: (name of drug, dosage, classification)

32
N365P Spring 2012

POSTPARTUM DATA SHEET

ASSESSMENT (cont'd.)

POSTPARTUM ORDERS CONTINUED:

Diet, activity, dressing change, treatments, etc.

DATA COLLECTION-LAB TESTS: Please include a printout or write down all lab values
(per hospital's policy). Include pre- and post-delivery lab data (CBC before and after birth, T&S,
RPR, HIV, HBSAG, etc.). Highlight abnormal labs and indicate probable reason. Submit
explanations and source used on separate page.

TEST DATE/TIME AGENCY CLIENT RATIONALE

VALUE VALUE

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N365P Spring 2012

POSTPARTUM DATA SHEET

ASSESSMENT (cont'd.)
ASSESSMENT - Physical Exam

VS
IV (if present)
Lungs
CV (pulses, Homan's, edema, cardiac)
GI/GU
Breasts/Nipples
Incision (if present)
Uterus/Lochia
Perineum/Hemorrhoids

Nursing Diagnoses - (list in order of importance) (Diagnoses must include three part
statement unless high risk DX.)
1.

2.

3.

4.

5.

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N365P Spring 2012

Clinical Objectives for Care of the Family During the Intrapartum Period

Objective: Provide nursing care in a family-centered manner that promotes healthy family
interactions.

1. Obtain the history and admission information from patient being admitted to the labor
and delivery unit.

2. Assess assigned intrapartum family, including:

a. type of childbirth preparation, if any

b. family's objectives for birth experience
c. uterine contractions (frequency, duration, intensity)
d. fetal heart rate (baseline, accelerations, deceleration, and variability)
e. behaviors indicative of latent, active and transitional phases of first stage of labor
f. psychological response to labor and birth

3. Develop a plan of care, incorporating patient and family needs, that maintains and
promotes the general well-being of the family throughout each stage of labor and
delivery.

4. Provide appropriate nursing interventions for healthy intrapartum patients and families:

a. support and comfort measures

b. catheterization
c. abdominal shave prep
d. administration of p. o. and parenteral medications
e. venipuncture
f. set up and regulate IV solutions (with exception of Pitocin)
g. attach external fetal monitor
h. monitor maternal blood pressure, temperature, pulse, and respiration
i. obtain and/or assist with lab specimens
j. assist with special procedures such as
- amniotomy
- ultrasound/biophysical profile
- non-stress test
- stress test
k. assist coach in performance of support measures as appropriate

5. Report deviations from normal immediately to primary nurse or instructor and provide
appropriate nursing actions for:

a. fetal bradycardia or tachycardia

b. decelerations
c. uterine tachysystole
d. increase or decrease in vital signs of mother

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N365P Spring 2012

e. difficulty in coping
f. unusual bleeding

6. Correctly position patient prior to epidural anesthetic. Provide appropriate nursing care
prior to, during and following administration of epidural anesthesia.

7. Assist in the preparation of a family having a Cesarean birth.

8. Assess parents' response to their newborn immediately following the birth.

9. Perform APGAR at 1 and 5 minutes; validate results with RN or instructor.

10. Implement a plan of care for a family in the fourth stage of labor, focusing on:

a. monitoring of vital signs

b. palpation and massage of fundus
c. evaluation of lochia flow and episiotomy/perineum
d. palpation of urinary bladder and prevention of distention
e. fluid and nutritional needs
f. comfort measures
g. facilitating parent-infant interaction
h. facilitating breastfeeding
i. facilitating sibling-infant interaction when appropriate

11. Evaluate plan of care for assigned intrapartum families.

Labor and Delivery Audiovisual References

Title Format Call Number Year Time

Labor and Delivery for Teens Video WQ 150 L123 1996 28 min
Healthy Steps for Teen Parents. Prenatal Care Video WQ 150 H434 Prog 1 2003 25 min
Healthy Steps for Teen Parents. Labor and Video WQ 150 H434 Prog 2 2003 25 min
Delivery
Gentle Birth Choices Video WQ 150 G338 1996 47 min
Giving Birth: Challenges and Choices Video WQ 150 G539 1998 35 min

Comfort Measures for Childbirth Video WQ 150 C732 1995 42 min

Pregnancy Labor and Delivery DVD WQ 200 L122 2004
Prog 1: Pregnancy
Prog 2: Labor and Delivery
Prog 3: Pain Control
Prog 4: Leopold’s Maneuvers.
Stages of Labor (2nd ed.) Video WQ 300 S7787 2006 28 min
Just in Case. Cesarean Video WQ 430 J96 1996 25 min

36
N365P Spring 2012

LABOR AND BIRTH DATA SHEET

Student Date of Care
Delivery Method Date/Time of Birth

I. ASSESSMENT: DATA COLLECTION-HISTORY

Pts initials Prenatal Care Provider:

Age Allergies Private (physician's initials):
Race/Ethnic group or Clinic (initials)
Blood type and Rh Social Support: (Include formal or common law
Maternity History marital status, household members, significant others)
Gravida______________ Para ___________
T (Term) _____ P (Premature) ____ A ____ LC ____

Current pregnancy: LNMP Personal Medical and Surgical History:

Gestation week when prenatal care begun:

EDC
Dating Criteria Significant Family History:

Complications/problems during this pregnancy

Admission Data: Date
Time Reason
FHR Scheduled Procedures
Medications taken during current pregnancy Contractions:
Time of onset
Freq., duration, intensity on admission
Total weight gain
Childbirth preparation (may include classes on early Membranes on admission: Intact
pregnancy, birthing process, breastfeeding, etc.) Ruptured (date/time)
Fluid: clear meconium
odor odorless

Past obstetrical history: Initial Vaginal Exam: Date & Time

Year Gest. Total Hours Complications Delivery Dilation Eff. Station
of Labor Method Other information:

Last intake of food/fluid

Last slept

Anesthesia
(if applicable)

Medications administered during labor with explanation

Comments: of why medication was administered

37
N365P Spring 2012

LABOR AND BIRTH DATA SHEET

DATA COLLECTION: LAB TESTS

1) Prenatal labs: (found on prenatal record; most lab tests done on first visit).
Test Date(s) Results
Rubella
Antibody Screen
Diabetes Screen; GTT
Hct./Hgb.
RPR/VDRL
G.C.
Chlamydia
Hep B Surface Antigen
Sickle Cell
T.B. Screen
Herpes
Pap Smear
Group B Strep
HIV
MSAFP or MMS or TAST or
Nuchal Translucency
Other

Amniocentesis/CVS: Reason:
Ultrasound results and reason for ultrasound:
NST (number, reason):
Other lab tests:

2) Lab tests done during labor: include routine and any additional lab work. Please include a printout
or write out all lab. State rationale for labs ordered.

Test Reason Ordered Time Results

Explain all abnormal prenatal or intrapartal lab results: Cite author, title and page number of reference.

PHYSICIAN ORDERS: (Include orders for activity, monitoring, p.o. intake, IV fluids, medications, and
medical procedures during labor or pre-op care of c-section.)

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N365P Spring 2012

DATA COLLECTION –– LABOR

Introduction: Include pertinent information about the patient and family not asked for on Data Sheet or
that data that requires further explanation. (Use the following as a guide.)

Labor:

Stage I began _______________ (Time/Date); ended ______________________ (Time/Date)

Describe the pt.'s behavior and nursing and medical interventions during the latent, active and transition
phases. Include baseline V.S. with deviations (explain probable reason for deviations), FHR (specify
mode of assessing), contraction pattern (frequency, duration, intensity), pt.'s and coach's activity,
relaxation and breathing techniques, comfort measures, medications, epidural, (patient's response,
including BP, pulse, FHR characteristics), vag. exams, personality changes, IV, use of Pitocin (induction
or augmentation), urinary output, emesis. If patient has a c-section, report nursing interventions
performed, including preop teaching.

Stage II began at ___________________ AM/PM; ended at _____________________ AM/PM

Describe pt.'s response to pushing including positions used, V.S., FHR, vag. exams, anesthesia, forceps,
pt. & coach's participation and reactions, personality changes, shave prep, time of delivery, sex of infant.
If patient has a c-section, report type of incision, anesthesia and events in Delivery Room.

Stage III began at __________________ AM/PM; ended at ______________________ AM/PM

Describe baby's response (Apgar & physical assessment), pt. and coach's reaction and their interaction
with the baby, time of placenta delivery, amount of Pitocin added to IV, condition of fundus, and amount
of vaginal bleeding.

Stage IV began at _________________ AM/PM

Describe pt.'s reaction during recovery. Include V.S., condition of fundus, amount of lochia, condition of
perineum or surgical dressing, epidural status (if applicable), bladder, reaction of mother & coach,
parent/infant interaction.

Total hours labor = _______________

NURSING DIAGNOSES (list in order of importance) (Diagnoses must be fully written out including
three part statement unless high risk DX.)
1.

2.

3.

4.

5.

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N365P Spring 2012

Clinical Objectives for Care of the Newborn

Objective: Provide nursing care for a newborn infant in a manner that promotes healthy family
interactions.

1. Ensure patency of newborn's airway by positioning, postural drainage and correct

utilization of bulb syringe when necessary.

2. Provide safe newborn care (positioning, holding and transferring, bathing, diapering,
umbilical cord care, circumcision care, maintaining body warmth, breastfeeding, correct
formula if bottle feeding).

3. Verify the identity of an infant before initiating procedures; verify the identity of parents
before leaving an infant in mother's room.

4. Report deviations from normal immediately to primary nurse or instructor.

5. Record appropriate information regarding the status of the newborn (i.e. vital signs,
feedings, stools, urination and any deviations from normal.)

6. Perform a systematic physical assessment on a normal newborn, including:

- general measurements (vital signs, head & chest measurements)
- general appearance
- head-to-toe assessment
- assessment of clinical gestational age
- behavioral assessment (sleep/wake states)

7. Record findings of the physical exam accurately and concisely, using appropriate
terminology.

8. Assist parents in identifying infant states, behavioral cues and in knowing how and when
to interact with infant.

9. Prepare parents for care of infant at home by identifying their teaching needs and
implementing such.

Note: These objectives can be achieved in more than one setting, i.e. in the LDR Room,
Birthing Center, Postpartum Room or Newborn Nursery.

40
N365P Spring 2012

Care of the Newborn Audiovisual References

Title Format Call Number Year Time

Nutrition of the Infant Series Video WS 120 N976 2003

Prog 1. Diet During Pregnancy. 24 min.
Prog 2. Benefits of Breastfeeding. 24 min.
Prog 3. Techniques for Successful
Breastfeeding. 29 min.
Prog 4. Formula Feeding. 24 min.

Helping a Mother to Breastfeed Video 1990 20 min

Breastfeeding Kit—video, flipchart, mini breast Kit WS 125 B828 1997
pump, parent guides
Helping Parents Understand Their Newborn Video WS 105 H483 2003 35 min
Neonatal Behavioral Assessment Scale Video WS 105 N438 1999 22 min
Newborn Infant Care Video WS 113 N533 1998
The First Years Last Forever Video WS 113 F527 28 min
Nursing Care of the New Family: Infant Care Video WS 113 K73 1991 30 min
Touchpoints. Brazelton, T. Berry Video WS 113 1997
Vol 1. Pregnancy, birth & the first weeks T7227
Vol 2. The first month through the first year
Vol 3. One year through toddlerhood

Lamaze: You and Your Baby: Infant Care DVD WS 113 Y67 2004
Psychosocial Care. Infants and Toddlers Video WS 105 P371 1995 31 min
Smarter Than You Think Video WS 420 S636 19 min
Physical Assessment of the Normal Newborn Video WS 420 1986 34 min
P5778
The Infant Patient Encounter, Infant Exam CD WS 420 I43 2006

41
N365P Spring 2012

NEWBORN DATA SHEET

Student Date of Care

Baby's Initials Mother's Initials Gestational Age

Feeding Method Delivery Method: SVD C-Section

BIRTH DATA
Date & Time of Birth Blood type/Rh
APGAR / Coombs Test
Sex Mom’s Blood Type
Weight ______ lb. _____ oz / ______ gm
Length ______ inches / _______ cm
Head Circumference _________
Blood glucose (AccuCheck) __________ Time of Test __________
(if applicable)

SIGNIFICANT HISTORY OF MOTHER

Age _____ Gravida ____ Para ______ Term ___ Premature ___ A ___ LC ___ EDC ________

Prenatal: (Describe any health problems or exposure to detrimental environmental factors by

mother)

Intrapartum: (Include type of birth, total length of labor, medications, or anesthesia received
during labor, date, time and color of rupture of amniotic fluid, support system during labor and
birth, any problems during labor or birth.)

INTERACTION OF FAMILY WITH INFANT (describe observations):

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N365P Spring 2012

PHYSICAL EXAMINATION OF INFANT

Date & time performed

Vital signs: T __________ P __________ R __________

General appearance (Include muscle tone and state of arousal in description.):

Note: For each of the following areas of assessment, describe normal characteristics noted in
infant and any variations or deviations from normal. ("Normal," "WNL” or "Normal
Configuration" are not acceptable descriptions).

Skin:

Head:

Face:

Eyes:

Ears:

Nose:

Mouth and Throat:

43
N365P Spring 2012

Neck:

Chest/Respirations:

Heart:

Abdomen:

Genitalia:

Anus and rectum:

Extremities:

Spine:

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N365P Spring 2012

Reflexes Present Abnormal

Moro ______ _______
Palmar ______ _______
Plantar ______ _______
Sucking ______ _______
Rooting ______ _______
Swallowing ______ _______
Babinski ______ _______
Stepping (dance) ______ _______
Trunk incurvation ______ _______

Gestational Age: Date performed Determination weeks

SUMMARY OF ASSESSMENT FINDINGS: (Write out summary)

NURSING DIAGNOSES: (Diagnoses must be fully written out including three part
statement unless high risk DX.)

1.

2.

3.

4.

5.

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N365P Spring 2012

The University of Texas at Austin

School of Nursing
N365P Nursing Care of Childbearing Families Practicum
Spring 2012
CHILDBEARING CLINICAL COMPONENT – EVALUATION TOOL

Student: Instructor:

The critical elements in the student's evaluation are:

1. Delivers nursing care that prevents real or potential personal harm to childbearing families. Yes No
2. Demonstrates having a theoretical knowledge base necessary for clinical practice. Yes No
3. Demonstrates the use of communication skills necessary for patient safety. Yes No

If the clinical instructor observes nursing behaviors which are deemed to indicate that the student does not meet any one of these three critical
elements at a satisfactory or safe level, the student cannot pass the course. Failure to demonstrate safe performance of all three critical
elements is failure in the course, regardless of other nursing care proficiency in performing other behaviors or written work.

Dependent - 1 = Consistent inability to function safely in the student nursing role.

Marginal - 2 = Performance requires step-by-step assistance by instructors. Needs much work to improve.
Assisted - 3 = Needs some assistance with work organization, priority setting, planning and implementing care. Clinical preparation and
performance lacks depth.
Supervised - 4 = Generally is well organized. Sets appropriate priorities with some direction. Clinical preparation and performance is thorough.
Independent - 5 = Clinical performance and preparation is consistently outstanding (no supporting cues needed).
NA = Not assessed.

Objectives:
1. Application of Knowledge
1.1 Demonstrates clinical reasoning and problem-solving skills. NA 1 2 3 4 5

1.2 Demonstrates evidence of clinical preparation. Able to apply textbook and classroom NA 1 2 3 4 5
learning to clinical experience.

Supporting Data for Objective 1:

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N365P Spring 2012

2. Technical Competence
2.1 Safely performs nursing skills with dexterity and organization. NA 1 2 3 4 5

2.2 Reviews and verifies each patient’s written orders before delivering nursing care. NA 1 2 3 4 5

2.3. Administers medications safely using appropriate supplies and equipment. Accurately NA 1 2 3 4 5
verbalizes the medication pharmacology, usual dosages, expected responses of the patient,
and nursing implications.

2.4 Performs a complete postpartum assessment for cesarean and vaginal delivery. NA 1 2 3 4 5

2.5 Performs a complete intrapartum assessment. NA 1 2 3 4 5

2.6 Performs a complete newborn assessment. NA 1 2 3 4 5

Supporting Data for Objective 2:

3. Interpersonal Skills/Caring
3.1 Communicates effectively with patients, families, and the health care team. NA 1 2 3 4 5

3.2 Assesses family readiness for learning; identifies teaching needs, uses appropriate NA 1 2 3 4 5
terminology and evaluates teaching effectiveness.

3.3 Demonstrates compassionate behaviors and provides care according to philosophical, NA 1 2 3 4 5

religious and cultural beliefs and practices of the individual with nonjudgmental attitude.

3.4 Documents in a complete, accurate and timely manner. Uses appropriate terminology to NA 1 2 3 4 5
document pertinent data and patient teaching.

Supporting Data for Objective 3:

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N365P Spring 2012

4. Nursing Process
4.1 Monitors and assesses the patient’s clinical condition and gathers data. NA 1 2 3 4 5

4.2 Interprets all pertinent physiological, developmental, and psychological data. Identifies NA 1 2 3 4 5
changes in patient’s condition or response to treatment and intervenes appropriately.

4.3 Prioritizes nursing diagnoses and develops individualized plan of care. Goals are realistic, NA 1 2 3 4 5
appropriate, and measurable.

4.4 Develops evidence-based interventions that are related to specific nursing diagnoses and NA 1 2 3 4 5
goals.

4.5 Evaluates effectiveness of nursing actions and revises plan of care as needed. NA 1 2 3 4 5

Supporting Data for Objective 4:

5. Management
5.1 Assumes increasing independence and responsibility for patient care. NA 1 2 3 4 5

5.2 Organizes safe nursing care activities for 1 to 4 maternity and newborn patients efficiently NA 1 2 3 4 5
and effectively.

5.3 Acts as a patient advocate in managing patient care and protects patient confidentiality. NA 1 2 3 4 5

5.4 Collaborates with patient, family and health care team in planning, implementing, and NA 1 2 3 4 5
evaluating patient needs and nursing care.

5.5 Administers nursing care to prevent risks, errors, threats to patient safety and hazards or NA 1 2 3 4 5
complications due to illness or hospitalization.

Supporting Data for Objective 5:

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N365P Spring 2012

6. Accountability/Professionalism
6.1 Demonstrates a positive and responsible attitude (evidenced through behaviors) and NA 1 2 3 4 5
motivation to learn. Accountable for personal and professional behaviors.

6.2 Attends all clinical days and is punctual. Adheres to student dress code in all clinical NA 1 2 3 4 5
settings.

6.3 Demonstrates the professional standards of moral, ethical, and legal conduct. NA 1 2 3 4 5

Supporting Data for Objective 6:

Total points earned: _______/125 = _______%

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N365P Spring 2012

Clinical Practicum & Online Tests: 60%

Nursing Process Report 1: 15%

Nursing Process Report 2: 15%

Data Sheet without NPR: 3%

Oral Case Study: 5%

Post Tests: 2%

Final Summary Comments & Faculty Signature:

Final Student Comments and Signature:

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