The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation. Provides direct patient care within the scope of practice. The Registered Nurse also directs and guides patient/family teaching and activities of other nursing personnel while maintaining standards of care in the Birthplace. Is able to respond quickly and accurately to changes in condition and/or response to treatment. Provides for a safe environment for patients and visitors. Utilizes the chain of command when necessary to ensure patient well-being and appropriateness of care to newborns and mothers during the antepartum and postpartum periods.
Detects changes in the patient’s condition, including abnormal fetal heart rate patterns, labor progression, and takes appropriate action; documents and notifies physician in a timely manner.
Responds appropriately to infant/maternal emergencies at the time of delivery or as required.
Assists patient through the stages of labor and prepares adequately for the safe delivery of neonate including supplies and appropriate personnel/environmental preparation.
Accurately performs APGAR scoring.
Completes and attaches and double checks maternal/infant identification bands; Provides parental education regarding the critical importance of bands/security.
Assures delivery rooms/C-Section rooms are properly prepared for any emergency or delivery and that all equipment including suction, oxygen and resuscitation supplies are present and in good working order.
Recognizes signs of abuse and reports appropriately to the hospital social worker and/or Child/Adult Protective Services. Familiar with the EMTALA Regulations.
Ensures consistently that all clinical alarms, i.e. cardiac and/or fetal heart rate monitors are set with the appropriate parameters for the patient and are audible at all times.
Is in compliance with information contained in the Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guidelines), and demonstrates appropriate use of personal protective equipment (e.g., gloves, gowns, masks, goggles) and hand hygiene techniques.
Gives thorough, detailed efficient change of shift report or upon patient intra-department transfer to ensure consistency in the plan of care. Uses the SBAR communication methodology in all reporting.
Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e. suction and oxygen immediately available when needed.
Completes pain assessment and reassessment consistently within the time frame after giving pain medications and upon discharge or transfer of patients.
Completes documentation of medications given to the patient on the Medication Administration Record (MAR) and narcotic sheet.
Detects and reports medication errors and ADR’s according to hospital policy. Safely and accurately administers medications and documents properly on the MAR in a timely manner.
Ensures Crash Cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist.
Assists physicians with deliveries, special tests and procedures in the unit. Uses universal protocol “time out” on all patients for any invasive / bedside procedures.
Responsible for the observation and direction of patient lifts, mobilization, and shall participate as needed in patient handling.
Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques, includes but not limited to 1) Appropriate use of lifting devices and equipment, 2) Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation, 3) Use of lifting devices to handle patients safely.
Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.
Uses two patient identifiers consistently when drawing lab, administering medications and performing procedures. Follows medication reconciliation policy consistently.
Does not use unacceptable abbreviations in documentation (uses read back on all telephone orders.) Monitors authentication and validation of telephone orders within 24 hours by the physician.
Performs all other duties as assigned or required.
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