NCLEX Maternal Antepartum
Assessment Questions with Rationales
graded A+
1. A nursing instructor is conducting lecture and is reviewing the functions of the
female reproductive system. She asks Mark to describe the follicle-stimulating
hormone (FSH) and the luteinizing hormone (LH). Mark accurately responds by
stating that:
A. FSH and LH are released from the anterior pituitary gland.
B. FSH and LH are secreted by the corpus luteum of the ovary
C. FSH and LH are secreted by the adrenal glands
D. FSH and LH stimulate the formation of milk during pregnancy.
2. A nurse is describing the process of fetal circulation to a client during a prenatal
visit. The nurse accurately tells the client that fetal circulation consists of:
A. Two umbilical veins and one umbilical artery
B. Two umbilical arteries and one umbilical vein
C. Arteries carrying oxygenated blood to the fetus
D. Veins carrying deoxygenated blood to the fetus
3. During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse
determines that the fetal heart rate is normal if which of the following is noted?
A. 80 BPM
B. 100 BPM
C. 150 BPM
D. 180 BPM
4. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells
a nurse that the first day of her last menstrual period was September 19th, 2013. Using
Naegele’s rule, the nurse determines the estimated date of confinement as:
A. July 26, 2013
B. June 12, 2014
C. June 26, 2014
D. July 12, 2014
Page 1 of 18
,5. A nurse is collecting data during an admission assessment of a client who is
pregnant with twins. The client has a healthy 5-year old child that was delivered at 37
weeks and tells the nurse that she doesn’t have any history of abortion or fetal demise.
The nurse would document the GTPAL for this client as:
A. G = 3, T = 2, P = 0, A = 0, L =1
B. G = 2, T = 0, P = 1, A = 0, L =1
C. G = 1, T = 1. P = 1, A = 0, L = 1
D. G = 2, T = 0, P = 0, A = 0, L = 1
6. A nurse is performing an assessment of a primipara who is being evaluated in a
clinic during her second trimester of pregnancy. Which of the following indicates an
abnormal physical finding necessitating further testing?
A. Consistent increase in fundal height
B. Fetal heart rate of 180 BPM
C. Braxton hick’s contractions
D. Quickening
7. A nurse is reviewing the record of a client who has just been told that a pregnancy
test is positive. The physician has documented the presence of a Goodell’s sign. The
nurse determines this sign indicates:
A. A softening of the cervix
B. A soft blowing sound that corresponds to the maternal pulse during auscultation
of the uterus.
C. The presence of hCG in the urine
D. The presence of fetal movement
8. A nursing instructor asks a nursing student who is preparing to assist with the
assessment of a pregnant client to describe the process of quickening. Which of the
following statements if made by the student indicates an understanding of this term?
A. “It is the irregular, painless contractions that occur throughout pregnancy.”
B. “It is the soft blowing sound that can be heard when the uterus is auscultated.”
C. “It is the fetal movement that is felt by the mother.”
D. “It is the thinning of the lower uterine segment.”
9. A nurse midwife is performing an assessment of a pregnant client and is assessing
the client for the presence of ballottement. Which of the following would the nurse
implement to test for the presence of ballottement?
Page 2 of 18
, A. Auscultating for fetal heart sounds
B. Palpating the abdomen for fetal movement
C. Assessing the cervix for thinning
D. Initiating a gentle upward tap on the cervix
10. A nurse is assisting in performing an assessment on a client who suspects that she
is pregnant and is checking the client for probable signs of
pregnancy. Select all probable signs of pregnancy.
A. Uterine enlargement
B. Fetal heart rate detected by nonelectric device
C. Outline of the fetus via radiography or ultrasound
D. Chadwick’s sign
E. Braxton Hicks contractions
F. Ballottement
11. A pregnant client calls the clinic and tells a nurse that she is experiencing leg
cramps and is awakened by the cramps at night. To provide relief from the leg
cramps, the nurse tells the client to:
A. Dorsiflex the foot while extending the knee when the cramps occur
B. Dorsiflex the foot while flexing the knee when the cramps occur
C. Plantar flex the foot while flexing the knee when the cramps occur
D. Plantar flex the foot while extending the knee when the cramps occur.
12. A nurse is providing instructions to a client in the first trimester of pregnancy
regarding measures to assist in reducing breast tenderness. The nurse tells the client
to:
A. Avoid wearing a bra
B. Wash the nipples and areola area daily with soap, and massage the breasts with
lotion.
C. Wear tight-fitting blouses or dresses to provide support
D. Wash the breasts with warm water and keep them dry
13. A pregnant client in the last trimester has been admitted to the hospital with a
diagnosis of severe preeclampsia. A nurse monitors for complications associated with
the diagnosis and assesses the client for:
A. Any bleeding, such as in the gums, petechiae, and purpura.
B. Enlargement of the breasts
Page 3 of 18
Assessment Questions with Rationales
graded A+
1. A nursing instructor is conducting lecture and is reviewing the functions of the
female reproductive system. She asks Mark to describe the follicle-stimulating
hormone (FSH) and the luteinizing hormone (LH). Mark accurately responds by
stating that:
A. FSH and LH are released from the anterior pituitary gland.
B. FSH and LH are secreted by the corpus luteum of the ovary
C. FSH and LH are secreted by the adrenal glands
D. FSH and LH stimulate the formation of milk during pregnancy.
2. A nurse is describing the process of fetal circulation to a client during a prenatal
visit. The nurse accurately tells the client that fetal circulation consists of:
A. Two umbilical veins and one umbilical artery
B. Two umbilical arteries and one umbilical vein
C. Arteries carrying oxygenated blood to the fetus
D. Veins carrying deoxygenated blood to the fetus
3. During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse
determines that the fetal heart rate is normal if which of the following is noted?
A. 80 BPM
B. 100 BPM
C. 150 BPM
D. 180 BPM
4. A client arrives at a prenatal clinic for the first prenatal assessment. The client tells
a nurse that the first day of her last menstrual period was September 19th, 2013. Using
Naegele’s rule, the nurse determines the estimated date of confinement as:
A. July 26, 2013
B. June 12, 2014
C. June 26, 2014
D. July 12, 2014
Page 1 of 18
,5. A nurse is collecting data during an admission assessment of a client who is
pregnant with twins. The client has a healthy 5-year old child that was delivered at 37
weeks and tells the nurse that she doesn’t have any history of abortion or fetal demise.
The nurse would document the GTPAL for this client as:
A. G = 3, T = 2, P = 0, A = 0, L =1
B. G = 2, T = 0, P = 1, A = 0, L =1
C. G = 1, T = 1. P = 1, A = 0, L = 1
D. G = 2, T = 0, P = 0, A = 0, L = 1
6. A nurse is performing an assessment of a primipara who is being evaluated in a
clinic during her second trimester of pregnancy. Which of the following indicates an
abnormal physical finding necessitating further testing?
A. Consistent increase in fundal height
B. Fetal heart rate of 180 BPM
C. Braxton hick’s contractions
D. Quickening
7. A nurse is reviewing the record of a client who has just been told that a pregnancy
test is positive. The physician has documented the presence of a Goodell’s sign. The
nurse determines this sign indicates:
A. A softening of the cervix
B. A soft blowing sound that corresponds to the maternal pulse during auscultation
of the uterus.
C. The presence of hCG in the urine
D. The presence of fetal movement
8. A nursing instructor asks a nursing student who is preparing to assist with the
assessment of a pregnant client to describe the process of quickening. Which of the
following statements if made by the student indicates an understanding of this term?
A. “It is the irregular, painless contractions that occur throughout pregnancy.”
B. “It is the soft blowing sound that can be heard when the uterus is auscultated.”
C. “It is the fetal movement that is felt by the mother.”
D. “It is the thinning of the lower uterine segment.”
9. A nurse midwife is performing an assessment of a pregnant client and is assessing
the client for the presence of ballottement. Which of the following would the nurse
implement to test for the presence of ballottement?
Page 2 of 18
, A. Auscultating for fetal heart sounds
B. Palpating the abdomen for fetal movement
C. Assessing the cervix for thinning
D. Initiating a gentle upward tap on the cervix
10. A nurse is assisting in performing an assessment on a client who suspects that she
is pregnant and is checking the client for probable signs of
pregnancy. Select all probable signs of pregnancy.
A. Uterine enlargement
B. Fetal heart rate detected by nonelectric device
C. Outline of the fetus via radiography or ultrasound
D. Chadwick’s sign
E. Braxton Hicks contractions
F. Ballottement
11. A pregnant client calls the clinic and tells a nurse that she is experiencing leg
cramps and is awakened by the cramps at night. To provide relief from the leg
cramps, the nurse tells the client to:
A. Dorsiflex the foot while extending the knee when the cramps occur
B. Dorsiflex the foot while flexing the knee when the cramps occur
C. Plantar flex the foot while flexing the knee when the cramps occur
D. Plantar flex the foot while extending the knee when the cramps occur.
12. A nurse is providing instructions to a client in the first trimester of pregnancy
regarding measures to assist in reducing breast tenderness. The nurse tells the client
to:
A. Avoid wearing a bra
B. Wash the nipples and areola area daily with soap, and massage the breasts with
lotion.
C. Wear tight-fitting blouses or dresses to provide support
D. Wash the breasts with warm water and keep them dry
13. A pregnant client in the last trimester has been admitted to the hospital with a
diagnosis of severe preeclampsia. A nurse monitors for complications associated with
the diagnosis and assesses the client for:
A. Any bleeding, such as in the gums, petechiae, and purpura.
B. Enlargement of the breasts
Page 3 of 18
