ashleyisawesome

Haha WOW!, I graduated 8 years ago, but I do vaguely remember the critical thinking test. It wasn't knowledge based or really something you could study for. It was literally just critical thinking questions. I think they gave you a few paragraphs of a scenario of some kind (not nursing related) and then it asked questions what you would do in that situation. Like I said, there is no real way to study for it. It's just to assess how strong your critical thinking skills are. I guess you could Google critical thinking questions, but I wouldn't bother. Either you have good critical thinking skills or don't, you aren't going to gain them in a few weeks before the test.

Have you read the ARRIVE study? 39 week eIOLs are becoming more common due to the study saying it actually reduces the risk of c-section and still birth in primips, regardless of bishop score. I am not sure if ACOG has officially changed their recommendation yet, but I have heard they are going to. My hospital recently changed it's policy. In the past 39 week electives were allowed, but they had to have a favorable cervix. Now they allow them even if the patient is closed thick and high.

My unit's protocol is that anyone (with diabetes) in active labor who has 2 blood sugars in a row that are over 100 gets put on an insulin gtt, and yes we titrate them on our unit. The patient is automatically 1:1 and gets hourly blood sugars until they are off the gtt. The gtt is usually d/c'd once they deliver unless they are type 1 DM, then endocrinology is consulted and they decide what to do with it, but they remain on our postpartum unit unless they are in DKA or something and need to move to stepdown or ICU. I also did insulin gtts when I worked on med/surg, often with a 6 patient assignment.

Our charge nurse is usually the designated baby nurse (though if multiple deliveries are going on at once or charge is busy, she can call another nurse to go be baby nurse). In a lady partsl delivery we "catch" the baby, do initial resuscitation, assign apgars, trim the cord, put on diaper and hat, put baby skin to skin, fill out and apply ID bracelets, and do the first set of vital signs. If mom doesn't want to or can't do skin to skin, we also do foot prints and weight at that time. The rest of the vitals (q30 x4) are done by the labor nurse who is also recovering mom. After mom is done doing skin to skin/feeding, the nursery nurse comes to the room to do the admission assessment and give shots/erythromycin, put alarm bracelet on, and put shirt/socks on. The nursery nurse also enters all of the orders ahead of time once baby is born. If the baby needs an immediate bath (HIV or Hep C), the baby nurse will do it, otherwise it's done in postpartum 12+ hours later. In a C-section the baby nurse catches the baby, brings it to the warmer for NICU to check out, helps with resus if needed, gets foot prints, applies bracelets, then brings baby to mom for skin to skin if desired or just for a little snuggle if no skin to skin is wanted right away. If they are doing skin to skin we stay and do vitals q30 for as long as mom is holding baby. If they don't do skin to skin, we then take them to the nursery with dad following us, weigh them and hand them off to the nursery nurse who does the admission assessment and meds and monitors baby until mom is brought to PACU and then baby is brought in to be with mom. If vitals still need to be done at that time the labor nurse who is caring for mom in PACU finishes them. If it's twins we have two baby nurses and one will usually stay for the duration of recovery to help the labor nurse out with all the vitals and stuff.

We used to take 16 hours of call per 6 week schedule in 4 hour increments, they have recently changed it to 8 hours. Only part time nurses have to do it (.9 or less), and if you do charge you don't have to sign up for call. We get paid $5/hr to sit at home on call, then base rate if we get called in. We get time and a half if it puts us into overtime though. Everyone hates it, but when I am working short staffed I am grateful to have someone called in to save us.

We throw a pulse ox on them and assess the pulse continuously through the test dose and until they lay down. I cycle B/Ps q3m starting when the test dose is given and switch it to q15 when I think they are stable (usually about 20-30 mins after they lay down). They stay on q15 min b/p and pulse checks throughout the rest of labor and fetal heart tones are charted q15 as well (can be q30 without epidural if low risk). If they receive any top off/boluses later I put them on q3m b/ps for a little bit after (usually 20 mins).

A lot of it will vary based on provider/facility. You will likely be admitted through OB triage either because your water broke or you have been having contractions and your cervix has dilated enough that they think you are in labor. If you come in in early labor, you may be sent home and told to come back when contractions get more intense/regular, or you may stay in triage for a couple hours getting re checked to see if you are making change. If you have a scheduled induction you will show up at a date and time agreed upon with your doctor and put right in a room. There are different kinds of inductions (cervical ripening, mechanical, pitocin, AROM). Inductions usually take a long time, especially in first time moms, so if you are being induced, be prepared to be there for a while (not unusual to have the baby a day or two after the induction starts). lady partsl exams will vary. Where I work if someone is on pitocin they get checked every two hours, but if they are resting comfortably their check might be deferred another 2 hours. If they aren't on pit there are no hard and fast rules but many times we stick to the every 2 hours, or when mom is feeling changes/we see changes in the fetal heart rate. You can refuse a check if you don't want one at that time. They are kind of uncomfortable (more so for some people than others), but once you have an epidural they are relatively painless. You can decline most interventions. Your provider will go over the risks and benefits of each before doing them. Generally any intervention we do is for the benefit of you and/or the baby. Some things may be non-negotiable like fetal monitoring if you are hooked up to certain meds/have certain risks, IV fluids if you have an epidural, a catheter (either straight cath or foley) if you have an epidural, etc. There is no real ideal patient, every birth is different. As long as you are kind and respectful to your nurses/doctors, we don't care that much. We can handle a little yelling and swearing during labor (just don't take it out on us--take it out on your partner if you must, haha.) Your provider will be able to answer a lot of your questions. Also ask about doing a tour of the L&D unit. They will explain a lot of their procedures and you will have an idea of what will go on at that particular facility. Good luck!

I have coworkers that have gone on to work in the OR, PACU, NICU, ED, Dr Offices, ICU, med/surg, peds, psych, home health, and probably some other areas I'm not thinking of. L&D is a varied specialty and you will learn a lot. You can spin the experience to work in your favor for almost any specialty. It's good for an ICU nurse because you learn how to deal with complex patients on a 1:1/1:2 ratio, you will learn a lot of the basics you'd learn in med/surg (gtts, I&Os, prioritization, assessment, communication with physicians, etc). You might not be coding patients a lot (hopefully), but you deal with a lot of emergent situations like hemorrhages, stat c-sections, shoulder dystocias, uterine ruptures, abruptions, precipitous deliveries, eclampsia, etc. A lot of our patients have comorbidities like DM, HTN, seizure disorders, psych issues, heart defects, etc. I have even had paralyzed patients that I had to do incontinence and wound care on! You will become very familiar with a well newborn assessment which will help you if you move on to PICU one day. There is also a ton of parent education which is great practice if you want to work in a PICU--you will be dealing with scared parents a lot! Remember there are a lot of roles an L&D nurse fills. Along with caring for a delivering mom and her baby in labor, you might also end up helping with neonatal resuscitation, in the OR as a scrub or circulator, in PACU recovering a fresh post op, in triage dealing with anything from rule out rupture/labor to yeast infections, to preterm labor and obstetrical emergencies. If you work in an LDRP you will also care for postpartum couplets, which is a lot like med/surg lite. And as a new grad, you aren't losing any skills by starting in any specialty. You can only gain skills. Don't take this negatively, but as a new grad you don't really have any skills to lose. For instance I don't know the first thing about caring for a patient on a ventilator, because I have never had to. I may have seen or cared for a few in nursing school under the guidance of other nurses, but in no way would I have ever said "I can take care of vent pts because I learned that in school." I am sure I could learn how to if I picked up a job in ICU, but they wouldn't expect me to know how when I started and they would teach me. Any knowledge you become rusty on or skills you feel like you didn't use much in L&D will be learned on whatever floor you end up on next. That's why they have orientation.

Where I work, we are 1:1 in labor most of the time, 1:2 is an exception only when we are slammed and there is no other option. We are usually 1:3-4 in antepartum and we do continuous monitoring in those assignments if needed. We do sometimes take more than one patient on Mag. I never have an antepartum and a labor patient together unless it's one of those SHTF situations. We are 1:1 in the OR, and if our labor patient goes to the OR, we go with them and circulate (charge and NICU take care of the baby). We are a bit smaller than your unit, but we still do high risk deliveries and are moderately busy. We do about 300 deliveries a month with 10 labor rooms, 4 triage rooms, 4 PACU bays (can be overflow triage if need be), 2 OB ORs. We have a couple dedicated antepartum rooms, but can throw them in a postpartum room or a labor room if we need to. We have one charge nurse on with no assignment who attends deliveries as baby nurse. She is in charge of the whole unit including postpartum and nursery. A good chunk of the labor nurses and all of the nursery nurses are also trained to be baby nurse so we can call one of them if charge is in another delivery. We do everything we can to avoid doubling on labor patients. The triage nurse will take out a labor patient and charge will become the triage nurse. We will make a postpartum nurse split up her couplets and come take out a labor patient (most of our nurses are trained to all areas). We keep cervical ripening and foley bulb inductions in triage overnight until they are ready for pit or they rupture/go into active labor. We will call nurses at home and offer them double bonus to come in. In the rare cases we have to double up, we try to double up with the most uncomplicated patients. We definitely wouldn't be doubling very active labor patients, diabetics, twins, pre-eclamptics on mag/getting labetolol, demises, patients with intermittently bad strips, etc. The few times I've had to do it I've either had an early induction/PROM just starting pit, or an early labor patient with an easy antepartum who just needs NSTs or tones qshift. I think you are valid in feeling overwhelmed. I would be and I have been a labor nurse for 3 years.

I applied for L&D right out of nursing school and didn't get any call backs. I ended up working in med/surg for 3 years and applying for OB/NICU/Peds jobs sporadically during that time with no call backs. Finally one day my current manager was desperate enough to call me in for an interview (they had just lost ~10 RNs due to retiring/moving/becoming NPs). I was offered the job that day and have been here ever since. I had no prior OB experience.

If I worked at a place where there wasn't a physician on the floor at all times (ie, had to call them from home or another floor in the hospital), I might consider a sterile lady partsl exam to make sure there are no presenting parts in the lady parts or a prolapsed cord. I would definitely at least look at her lady parts and make sure nothing is hanging out (foot, cord, etc). Where I work there is always at least a resident and an attending close by (can be in the room in seconds) so I would just call for help and expect them do an SVE or speculum exam/ultrasound unless I saw cord protruding from the lady parts, because I don't usually stick my hands in preterm patients who aren't in labor when I have a doctor around to do it. I would probably call another nurse to bring a stretcher and keep it by the door, and make sure she isn't wearing jewelry and ask her when she last ate/drank, in case the doc calls a stat. I would continue to change positions until the doctor got there (left, right, knee chest).

When I admit a new patient or get them for the first time, I usually listen to heart/lungs/bowel sounds. Check for edema, feel pedal pulses, check for clonus, do a homans test, ask about pain, ask if they are having head ache/blurred vision, assess their amniotic fluid color/smell if they are ruptured, palpate contractions for intensity, and check all lines (including epidural if they have one) to make sure they are connected and running the right stuff. Then throughout my shift I do a more focused assessment every couple of hours. I only check DTRs if they are pre-eclamptic or on Mag.

Yeah, this is one of the changes I don't really mind at all. We get a lot less babies with low temps/sugars now that we do this, and breastfeeding retention is better (I am sure this also has to do with rooming in and better breastfeeding education for staff). Plus instead of taking the kid to the nursery to bathe, we do it right in the room and the parents can be involved and ask questions, which is a good learning experience for new parents.

When I first started, we did it like you currently do it. Labor nurse (usually the charge nurse, the moms primary nurse concentrated on mom) did resus/apgars (always straight to the warmer after cord was cut), we grabbed a weight and foot prints in the room, then handed baby to mom for a bit to nurse/hold and then usually around the 2 hour mark when we were ready to move mom to PP, we dropped baby off in the nursery for admission/bath/meds. Baby was returned to mom once it was warmed up after the bath. A lot of our staff is trained in labor and postpartum and we float back and forth, but there are some that only do labor or only do PP/nursery. Our nursery trained nurses could be baby nurse if we were in a pinch and charge was in another delivery. We went "baby friendly" a couple years ago. Now we still have the charge or another labor/nursery nurse catch baby and do resus. Baby goes straight to moms skin after delivery and Apgars/vitals/tactile stim/bulb suction are all done on moms chest. If they need more we whisk them over to the warmer. Weight/prints/meds/assessment are all done in the delivery room by the nursery nurse (we call her when we are ready) after mom has had at least 1 hour of skin to skin and attempted the first feed. Sometimes the labor nurse does the assessment, etc if it's an easy recovery and we have time. Baths are done 12 hours after birth in the PP room by either the PCA or the PP nurse. Baby and mom go to the PP room together and are never separated unless medically necessary or mom requests the baby go to the nursery for a bit so she can rest.

As someone who precepts, I prefer a nurse with experience, even in a different specialty. They already know how to start and IV, put in a foley, prioritize care, talk to doctors, etc. I can start just teaching them OB stuff instead of teaching them how to be a nurse first. That being said, I don't mind new grads either. They aren't set in their ways so you can mold them to be an OB nurse without training them to stop thinking like a medsurg/ER/ICU/etc nurse. I think getting NRP as a new grad with no experience is a waste. They likely won't remember anything from the class until they can put it into practice and make sense of it. I think it shows initiative and an interest in the specialty if they get it before landing the job, but I don't think it puts them at any advantage over a new grad who hasn't taken it.

I typically make a brain sheet with 6 boxes on it. One box for mom and one for baby. I put pertinent info on it as well as a check list of things that need to be done this shift. My checklist for baby usually includes things like: Assessment, weight, vitals, bath, PKU/Bili, feeds, etc. I also designate times to check feeds/output. Our moms have a feeding log they are supposed to fill out when they feed. Moms is usually: Assessment, fundal checks, meds, blood work. I usually round at 2000, 0000, 0400 and 0600 to check on feeds and amount of wet diapers. I lump other cares in with those times. I do my mom's fundal checks at 2000, 0000, and 0400. Q4 vitals on mom and baby are done at the same times. Once I do something on my check list, I put a check mark next to it. Once I chart it, I draw a line through it.

We hire new grads in Eastern PA. We have one male L&D RN and at least one other male RN on our OB unit at our other campus. We also have a male PCA.

So weird. Of those specialties, I feel postpartum is the easiest to pick up for a new grad. We are an LDRP, but we always start our new grads in postpartum for about a year before training them to labor.

1. Urine screen on all new admits - We get a urine sample on all admits, but set it aside and only send it for a UDS if pt is a known drug user, had no prenatal care, had spotty prenatal care, or we are suspicious for some reason (track marks, etc). We also sometimes use it for pre-eclamptic labs or a UA if we suspect UTI, so we aren't just making them pee for a UDS. 2. Admistering Nubain - We mostly give stadol. We have 2 physicians that sometimes give nubain in labor. We do give nubain after c-sections for itching r/t the duramorph. 3. Ultrasound on new admits - Definitely not on every patient. If they have no prenatal care (ie, no previous scans), are known to have an unstable lie, we are getting heart tones up high, we think we feel a butt or feet during cervical check or suspect breech via leopolds we will do a scan. 4. Pitocin- We do what the physician orders. If no physician is around and I am having a major decel, I will shut it off and ask questions later. If they are having subtle lates, I will discuss it with the physician. Sometimes they want it off, sometimes they want to decrease it and reasses in 30 mins. 5. Cord Blood Gas - We get it on all babies. No idea on it's cost effectiveness.

We let our kids go about 24 hours without a feed (but they have to be attempting during that time of course). We will only check a blood sugar if they are LGA/SGA, GDM, they have a low temp, or they appear jittery. We don't just check blood sugar q3 on a baby with no risk factors. We will get an order for formula if they have a low sugar, lose more than 7% of their birthweight, or have a high bili. I always encourage pumping or hand expression for a kid who doesn't properly latch after two attempts so we can at least syringe feed some colostrum. Sorry I don't have an literature on this, it's just what we do at my facility.

Pros: Less adult poop (there is still some!), 1:1 ratio, mostly young healthy patients (some not so healthy though, but at least their veins are usually young and plump), virtually no patients over the age of 50, getting to be involved in one of the most important times in people's lives, cute babies, generally happy atmosphere. Cons: Younger patients can sometimes be more demanding, especially if they've never been hospitalized before. Lots of concerned family members that want to tell you how to do your job. Life or death situations can happen in the drop of a hat. It can be insanely stressful. Babies die. Moms die. Babies addicted to drugs. Holding a leg for 4 hours when an epiduralized 400lb woman pushes, and then ends up with a c-section anyway. The workload is way different. Instead of juggling 6 patients I just have 1 (or two if you count the fetus, which I do!), but that one patient needs a lot of your time (hence the low ratio). I chart q15 mins, I always have my eyes on the strip, I am titrating pitocin, insulin, doing mag checks q2 hours, repositioning often, coaching them through breathing exercises to get through the pain, strict I&Os, etc. I need to be able to flop someone in a stretcher and get them to the OR in 3 mins or less in an emergency and circulate in the OR. In triage I can be balancing 4 needy patients at once (like a mini ER). Fetal demises are tough, tougher than an elderly death in med/surg IMO. Labor can be feast or famine and there are slow days with a lot of down time, or it can be running around like a chicken with your head cut off for the whole 12 hours. My record is 5 deliveries in one shift! That being said I totally recommend it. I will never go back. I have bad days in L&D, but I enjoy my good days way more than I ever did in med/surg. I do feel like my med/surg skills helped me. I already knew how to start an IV, place a foley, clean a patient, hang blood, etc. I just had to learn all of the labor specific stuff unlike a new grad starting from the beginning. Every once in a while we get a sick mom with something funky like a heart problem who needs an EKG, or a port-a-cath that I know how to access, and I come in handy! We even had a paralyzed patient once and knowing how to reposition her and how to assess for pressure ulcers was helpful. I am also sort of an IV wizard. I worked on a surgical floor previously so I was used to placing 18s and 20s in old dehydrated patients with roly poly veins, so putting them in a healthy young woman is no problem for me! (Most of the time, I still miss sometimes. haha)

Ours varies based on the nurses experience, how fast they learn and the unit needs. Generally we train to PP first, since it can be done quicker, then they work in a PP for a few months to get used to it and are trained in labor later. For each area (PP, Nursery, labor, OR/PACU, antepartum, triage, Resus/aka baby catcher) we have a checklist that your preceptor has to sign saying you are competent in those skills. There isn't a certain number of times you have to do a skill to get checked off, but in general it's a see one, do one with assistance, then do one independently and you get checked off (at least when I precept). PP orientation is about 4 weeks for nurses with prior experience in med/surg or another similar area, longer for a new grad. For labor training we spend anywhere from 12-16 weeks, sometimes more with a preceptor with labor patients. Once you are signed off and deemed ready to be on your own in labor, we get about 4 weeks of C-section training (including OR and PACU). We have them come in for day shift scheduled sections. Not everyone is trained to catch babies and it just kind of happens after you've been a labor nurse for a while (I think we should have more structured training in that department). We allow people to train to triage after 1 year of labor experience, but I've seen people just get thrown into it with no additional training (myself included). Some of the skills on the check list don't get done because you can't guarantee someone will get a hemorrhage, dystocia, etc, during orientation. In that case the preceptor goes over the policy with the preceptee and signs them off with a note that says "policy reviewed". We have trained some nurses to labor before postpartum. I don't really know how my manager decides who to train to what area first. We have the same issues with orientees getting pulled to postpartum due to high census when they should be training to labor.

We have a male nurse on our unit, and despite the other comments here, he is well liked by our patients. Of course there are always some patients who will request female staff only (especially for religious reasons, and since all the other nurses are female its easy to accommodate), but for the most part he rarely gets refused. We have a few multips who come back and ask if they can have him as their nurse again! He is part of our OR team, so from 7-3 he is usually either circulating in the OR or doing PACU, but he usually works until 7p and takes labor patients when there are no sections scheduled. He also does a few evening shifts in labor. He comes from an flight nurse background and is really knowledgeable and great to have around during emergencies. We also have a male PCA/scrub tech who is well liked by the patients.

This may be hospital dependent because our PP moms on mag are allowed to eat a regular diet as tolerated. They are on a fluid restriction though due to the risk of fluid overload. My best guess as to why some docs keep them NPO/Clear Liquids only is probably risk of aspiration from vomiting/decreased LOC.

I haven't had many actually panic. They get anxious, and a lot of them cry. I usually hold their hand and explain everything we are doing. I reassure them that we will make sure they are completely numb so they won't feel any cutting, but warn them about the pulling and pressure. I introduce them to the NICU staff and baby nurse and tell them their baby will be in good hands. Sometimes anesthesia will give them a little something in their IV to calm them down.