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OB Clinical
Assignment Packet

NRS 210/210C:
Nursing Concepts for the Multigenerational Childbearing Family

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Preparation for OB Clinical:

The OB Preparation Packet (which will require viewing the OB SIM video to
complete it) must be completed by the end of week 1.
 Will be available to view/download within mydsn.net (NRS210) and the
Simulation Google Classroom as of Monday Week 11, and on Blackboard on
Day 1/ Week 1 of the quarter.
Students will need to arrive at clinical with:
1. OB Clinical Packet
2. OB Preparation Packet (completed)
3. OB Assignment Packet (not completed, since it will be completed during
the clinical)
4. Completed set of Med Cards (can convert the med log from the OB
Preparation Packet into 3x5 cards); placing a ring through the cards makes
them easier to use, if possible.
Instructors will check students off for these items when they arrive at clinical on
Day 1; lack of completion of the OB Preparation Packet will warrant a fail.

During clinical, complete the OB Care Plan and Newborn Assessment:

Students must complete the OB Assignment Packet, which includes a

comprehensive OB Nursing Care Plan and a hands-on Newborn Assessment. A
grade of 78% or higher is required on each to pass the course. The care plan is
written on one patient (mom or newborn) and includes three nursing diagnoses,
as well as goals, interventions and rationales describing how the interventions
support the goals. The OB care plan will be written for a patient cared for in the
clinical setting and graded by the DCN Clinical Instructor. The newborn
assessment will also be graded by the DCN Clinical Instructor. If your clinical
rotation has a preceptor or clinical scholar (hospital employee), the assignments
will be graded by the OB Didactic Professor.

*Once your assignments are graded please upload the assignments and the
rubrics to Blackboard in a timely fashion.*

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OB Nursing Care Plan

Student name_______________________________________________________ Cohort _______

Patient identifier (initials), age, G/P ________________________________________________________

Relevant Antepartum/Intrapartum History (comprehensive) ____________________________________

_____________________________________________________________________________________

Current Labor/PP/NB Status (provide brief write-up of status) __________________________________

_____________________________________________________________________________________

Assessment data Nursing Dx #1 (PES)

(relevant per
nursing diagnosis)

SMART Goal (Pt Interventions (RN Rationale (how do Evaluation (met/not

will…) will…) interventions met AEB,
promote goal?) continuation plan)

1. 1.

2. 2.

3. 3.

Nursing Dx #2 (PES)

SMART Goal Interventions Rationale Evaluation

1. 1.

2. 2.

3. 3.

Nursing Dx #3 (PES)

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SMART Goal Interventions Rationale Evaluation

1. 1.

2. 2.

3. 3.

Rubric for OB Nursing Care Plans

Student Name: Cohort: Grade Awarded for Assignment:

*Please use this rubric as a guide when formulating your care plan. Use information from the patient,
the chart, and your hands-on assessment to create a personalized care plan for each patient. Listed
below are the criteria that will be used to grade your care plans.* MUST BE TYPE-WRITTEN

4 3 2 1 0

Criteria Excellent Very Good Fair Not

Good Acceptable
>90%of 80- 70- 60- < 60% met
criteria 90% 80% 70%
met met met met

Patient Information

 Patient identifier, age and G/P is included

 Comprehensive antepartum/ intrapartum

information, including complications, is
included

 Current Labor/ PP/ NB status (brief write-

up) is provided
Assessment Data:

 Should include data such as vital signs, lab

values, physical exam findings, assessment
of attachment and bonding, breastfeeding,

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etc.

 Chosen assessment data shows an

understanding of what to include as it
pertains to the nursing diagnosis

 Assessment (comprehensively, in the

entire care plan) reflects physiological,
psychological, sociocultural, spiritual, and
economic data, as well as other lifestyle
factors

Criteria 4 3 2 1 0

Excellent Very Good Fair Not

Good Acceptable

Nursing Diagnosis Statements

 Three [3] Nursing Diagnoses are

presented; two medical/ physical and one
psychosocial

 NANDA approved diagnoses are used

 Written in proper format (PES)

 Relevant to assigned patient per

assessment

 Listed from highest to lowest priority and

actual problems are listed before “risk for”
problems
Plan: Goal Statements
 One goal is written for each nursing
diagnosis
 Goals are patient-centered [PC] (Pt. will...)
 Goals are Specific, Measurable, Attainable,
Realistic, Time-specific [SMART]
Nursing Interventions

 Three interventions are presented per

goal, stated as instructions (“RN will”)

 Are specific (what/ when/ how often/ how

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much)

 Are related to goals

 Are prioritized, reasonable, and achievable

 Rationale for each intervention cited, using

APA format
Criteria 4 3 2 1 0

Excellent Very Good Fair Not

Good Acceptable

Evaluation and Revision of Plan

 Evaluation statements (one per goal) state

whether goal was met/ partially met/ not
met

 Evaluations directly reflect goal

statements

 A continuation of care plan is included

(e.g. ongoing monitoring, education at the
time of discharge, etc.)
General

 Care plan is readable, makes sense, is

practical and realistic; must be typed!

 Spelling and grammar are correct

 Rubric is attached to care plan

Score: ____________/100 (Maximum Score= 100 points) = _________%

Clinical Instructor/RN Signature Date

______________________________________________ _________________

*Students: Please attach this rubric to your OB Nursing Care Plan when you submit it for grading*

Newborn Assessment

Student name _____________________________________________ Cohort_________________

Newborn Time of delivery: APGAR 1/5/10 Birth weight _______grams

Identifier and
Birthdate:

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Current weight _____grams

Length: Head circumference: Chest Gestational (Circle one)

circumference: age:
_______cm ______cm
_________ cm
AGA SGA LGA

Maternal age ____________ G___/ P________ Blood Type _______ GBS Status ______________

Labor Hx: Onset/ total hrs of labor _______________________________________________________

AROM/ SROM time___________ Meconium stained fluid or terminal meconium? ______________

Maternal medications/ analgesia _________________________________________________________

Antepartum/ Intrapartum complications ___________________________________________________

Delivery: NSVD/ time __________________ Vacuum/forceps _______________________________

C/S: Planned/ Urgent/ Emergent Reason _____________________________________

Cord clamped at __________min. Skin-to-skin _______________min

Newborn resuscitation required? _________________________________________________________

Newborn blood sugar (in preterm, postterm SGA, LGA, maternal diabetic, other), give level __________

Bilirubin (TcB or TSB) ___________ CCHD result ____________ Hearing screen result ____________

First feeding @ ____________ min/ hr of life Type of feeding (breast/ bottle) __________________

Complete the following by circling or highlighting exam findings, include any deviations from normal.

CATEGORY OBSERVATIONS COMMENTS (include

abnormal findings)

General Color: pink/ pale/ acrocyanosis/ jaundiced

Appearance
Cry: strong/ weak/ high-pitched

Tone: normal (flexed)/ hypotonic/ hypertonic

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Skin Peeling/ rash/ bruising/ vernix/ petechiae/

mongolian spots

Head Molding/ caput/ open flat fontanels/ cephalhematoma

Eyes Clear/ discharge/ jaundice/ hemorrhage

ENT Intact palate/ normal ear setting/ patent nares/ nasal

flaring

Airway patent? Upper airway congestion?

Chest Symmetrical/ clavicle (intact)/ fractured (L R)

Nipple placement/ breast tissue

Chest movement symmetrical/ ribs symmetrical

Respiratory RR ____

Clear/ equal bilaterally/ retractions/ grunting/ coarse

breath sounds (eg, crackles)/ apneic episodes

Heart HR _______

Regular rate/ peripheral pulses bilaterally (femoral)/

murmur/ PMI

Abdomen Soft/ distended/ bowel sounds (present, diminished,

absent), umbilical vessels ____, cord clamp

Genitalia Male/ female/ ambiguous

Testes descended (R, L), undescended

Female: pseudomenstruation/ discharge/ appearance

Anus Placement normal/ meconium (present/absent)

Anal wink?

Spine Gluteal folds (equal/ unequal)/ pilonidal dimple

Spine straight/ curved

Extremities Symmetrical movement/ polydactyly/ syndactyly

Flexion (range of motion)/ muscle tone

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Reflexes noted Moro/ grasp/ suck/ rooting/ swallow/ babinski/ tonic

neck/ trunk incurvation/ step

State Quiet awake/ alert/ active/ sleeping/ crying

Note other relevant care data, including maternal/infant interactions:

_____________________________________________________________________________________

Complete the following newborn pain assessment by circling or highlighting findings.

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Rubric for Newborn Assessment

Student Name: Cohort: Grade Awarded for Assignment:

10 9 8 7 6 5

Criteria Excellent Very Good Fair Poor Not

Good Acceptable
>90% of 70- 60- < 60%
criteria 80- 80% 70% met < 50% met
met 90% met met
met
1. Apgar score noted/ measurements
and gestational age accurately noted

2. Newborn testing accurately noted

(blood sugar, TcB/ TSB, CCHD, hearing)

3. Maternal data recorded accurately

4. Data relevant to delivery and

associated events or any
antepartum/intrapartum
complications

5. Labor history, including duration ROM

and mode of delivery noted

6. Medications in labor noted

7. Feeding information recorded

8. Head-to-toe assessment accurately

documented

9. NIPS score accurately documented

10. Student observed performing exam

and recording data
Clinical Instructor verifies observation of Newborn exam: Date

___________________________________________________ ____________________

Score: ________/100 (Maximum Score= 100 points) = ___________%

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*Students: Please attach this rubric to your Newborn Assessment when you submit it for grading*

Brief Head-to-Toe Assessment

This Brief Head-to-Toe assessment guide is a summary of the most common assessments done by
nurses in the acute care setting. Nursing students need to practice these often to develop their own
style of a thorough yet quick assessment of the patient’s status. Once the BHT is completed, if findings
are abnormal, nurses must decide and prioritize their next course of action through following the
remaining steps of the nursing process. **All palpation and auscultation must be done directly on the
skin** Please remember this assessment is only for reflection and is not to substitute a full head to toe
as appropriate for your patient. Pregnant women have additional assessment needs.

As you enter the patient’s room:

SWIPE – See Universal Safety Protocol
Observe patient & their response as you perform SWIPE as this initial communication will help you
assess the patient’s neuro status, thought processes, speech, etc.
Vital Signs:
T: __________ P: __________ R: __________ BP: __________ (manual) SpO2: ______ O2 delivery: ____
Pain: (OPQRSTU) ____________________________________________________________________
General Survey:
 Neuro: appearance, behavior, hygiene, affect, mood, eye contact
 Overall skin color; Breathing effort (rhythm & depth)
Head:
 Level of Consciousness: Alertness and Orientation to person, place, time, situation; If altered, use
GCS
 HEENT: symmetry/movement, deformities, skin integrity; PERRLA
(Perform associated Cranial Nerve assessments as indicated)
Thorax:
 Respiratory: inspect chest for shape and respiratory effort; auscultate anterior/posterior lung
sounds
 Cardiac: auscultate APEtoMan (S3/S4 sounds? murmurs?); auscultate apical HR for 1 minute
 Gastrointestinal: inspect abdominal contour; auscultate bowel sounds in all 4 quads; light palpation,
last BM
 Genitourinary: consider ability to void, incontinence, indwelling catheter placement and condition
Upper Extremities: (anterior/posterior)
 Skin: Inspect for overall skin color and intactness; IV lines (peripheral); fingernail shape/condition
 Cardiac: Inspect color, Palpate for temperature, edema, radial pulses & capillary refill on fingers
 Musculoskeletal/Neuro: Inspect for deformities; Assess shoulder shrug, arm & grip strength and
sensation bilaterally
Lower extremities: (anterior/posterior)
 Skin: Inspect for overall skin color and intactness
 Cardiac: Inspect color, Palpate for temperature, edema, pedal pulses & capillary refill on toes
 Musculoskeletal/Neuro: Inspect for deformities, check foot pushes, leg lifts, and sensation
bilaterally; May assess gait with the Get Up and Go test

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Medication Preparation Log

Student Name: _________________________________________________________________ Cohort _________________________

Clinical Rotation Date: _________________________

Patient Identifier: Diagnosis:

Code Status:

Allergies: Relevant Medical/Surgical History:

Pt. Dose/ Reason pt. Nrsg Implications/ MUST

Drug (Generic/Trade) Normal Range Route Frequency Classification receiving RX Top 4 Side Effects KNOW

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Pt. Dose/ Reason pt. Nrsg Implications/ MUST

Drug (Generic/Trade) Normal Range Route Frequency Classification receiving RX Top 4 Side Effects KNOW

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DCN Universal Safety Protocol

SWIPE In
State your name & title/ Scan environment
Wash hands
Identify patient (name/DOB)
Provide privacy
Explain procedure/Ask Permission

BRowN COW Out

Bed low
Rails up (cannot restrain)
Needed items in reach

Call light in reach

Open privacy curtain
Wash hands

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