Antepartum & High-Risk Pregnancy NCLEX Practice Questions

Naegele's rule: take the first day of the LMP, subtract 3 months, add 7 days, then add 1 year. Starting with June 15, 2025: subtract 3 months to reach March 15, add 7 days to reach March 22, and add 1 year to reach March 22, 2026. That makes March 22, 2026 correct.

March 8, 2026 is wrong because it subtracts 7 days instead of adding them; the rule adds 7 days after moving back 3 months, so counting backward gives the wrong day. September 22, 2025 is wrong because it adds 3 months to the LMP instead of subtracting them; adding months moves the date the wrong direction and lands only about 3 months out, far too early for a term pregnancy. December 22, 2025 is wrong because it reflects an incorrect month shift (adding about 6 months instead of subtracting 3) and also fails to add the full year, producing a date only about 6 months after the LMP rather than the expected ~40 weeks.

Clinical pearl: a normal pregnancy is about 280 days (40 weeks) from the LMP, so a correct EDD should always fall roughly 9 months plus a week after the LMP. If your calculated date is only a few months out, you moved the months the wrong way. Memory aid: 'minus 3, plus 7, plus 1 (year).' Always confirm the client reports the FIRST day of the LMP, since using the last day skews the estimate.

GTPAL stands for Gravida (total pregnancies including the current one), Term births (37 weeks or later), Preterm births (20 to 36 6/7 weeks), Abortions/losses before 20 weeks, and Living children. Count each pregnancy once, even a multiple gestation.

Gravida = 4: the current pregnancy, the term son, the twin pregnancy (ONE pregnancy), and the miscarriage. Term = 1: the son at 39 weeks. Preterm = 1: the twins at 34 weeks (a single preterm birth event). Abortions = 1: the miscarriage at 12 weeks (before 20 weeks). Living = 3: the son plus both twins. That yields 4-1-1-1-3.

5-1-1-1-3 is wrong because it counts the twins as two pregnancies (Gravida); a multiple gestation is one pregnancy. 4-1-1-1-4 is wrong because it overcounts Living children as 4—she has three living children (one son and twins). 4-2-1-1-3 is wrong because it lists Term as 2, but only the 39-week son qualifies as term; the twins were born at 34 weeks and belong under Preterm.

Clinical pearl: 'Twins fool the count.' For Gravida and the T/P/A birth columns, count the PREGNANCY once (twins = one preterm birth), but under Living, count each surviving child individually. Also remember the 20-week and 37-week cutoffs: losses before 20 weeks go under A, births at 20 to 36 6/7 weeks are preterm, and 37 weeks or later is term.

These symptoms describe supine hypotensive (aortocaval) syndrome, in which the heavy gravid uterus compresses the inferior vena cava (and aorta) when the client lies flat, reducing venous return, cardiac output, blood pressure, and placental perfusion. The immediate, definitive fix is to relieve the compression by turning the client onto her LEFT lateral (side-lying) position, which shifts the uterus off the vena cava and restores circulation—often resolving symptoms within minutes.

Administering oxygen may be added supportive care, but it does not correct the underlying mechanical compression, so it is not the priority first step. Elevating to a high-Fowler position keeps the client largely supine relative to the vena cava and does not reliably move the uterus off the vessel; repositioning laterally is what works. Increasing IV fluids and notifying the provider might follow if symptoms persist, but these are slower and secondary; the fastest correction is simply repositioning, which requires no order.

Clinical pearl: 'Left is best.' Left lateral positioning maximizes uteroplacental and renal perfusion and is the go-to for maternal hypotension, late fetal heart rate decelerations, and epidural-related hypotension. Teach pregnant clients after about 20 weeks to avoid lying flat on their backs and to rest on their side. If left lateral is not possible, any side-lying or a wedge under the right hip to tilt the uterus off midline helps.

Danger signs in pregnancy that require prompt reporting include vaginal bleeding, visual disturbances, severe or persistent headache, and decreased fetal movement—so those four are correct. Vaginal bleeding can signal placenta previa, abruptio placentae, or preterm labor. Blurred vision/spots and a severe, persistent headache are hallmark severe features of preeclampsia (cerebral edema and vasospasm) and demand immediate evaluation. A decrease in fetal movement can indicate fetal compromise and warrants assessment (kick counts, nonstress test).

Mild ankle swelling at the end of a long day is an expected finding of late pregnancy from venous stasis and fluid retention; it is dependent edema, not the facial/hand edema that suggests preeclampsia, so it does not require urgent reporting. Increased urinary frequency is a common, benign change caused by the enlarging uterus and increased renal blood flow (and returns near term); it is only concerning if accompanied by dysuria, urgency, or fever, which would suggest a UTI.

Clinical pearl: teach the classic preeclampsia trio to report—severe headache, visual changes, and epigastric/RUQ pain—plus bleeding, leaking fluid, regular preterm contractions, painful urination, decreased fetal movement, and persistent vomiting. Distinguish EXPECTED changes (dependent ankle edema, urinary frequency, mild fatigue) from RED FLAGS. A quick screen: swelling of the FACE and HANDS is worrisome; swelling limited to the feet/ankles late in the day usually is not.

Group B strep is a normal vaginal/rectal colonizer that can be transmitted to the newborn during passage through the birth canal, causing serious neonatal sepsis, pneumonia, or meningitis. The standard of care for a GBS-positive culture (collected at 36 to 37 weeks) is intrapartum IV antibiotic prophylaxis—typically penicillin G—given during labor, ideally at least 4 hours before delivery. This is why receiving IV antibiotics during labor to protect the newborn is correct.

Treating with oral antibiotics before labor is wrong because GBS colonization recurs; clearing it antenatally does not prevent newborn exposure, so prophylaxis is timed to labor when transmission actually occurs. Saying the newborn needs no monitoring is wrong and dangerous—the entire rationale for prophylaxis is neonatal risk; infants of GBS-positive mothers may still be observed for signs of early-onset sepsis. Scheduling an immediate cesarean is wrong because GBS status alone is not an indication for cesarean; vaginal birth with IV prophylaxis is appropriate, and cesarean carries its own surgical risks.

Clinical pearl: universal GBS screening occurs at 36 0/7 to 37 6/7 weeks. Treat intrapartum, not antepartum. Also give intrapartum prophylaxis regardless of culture if there is GBS bacteriuria this pregnancy, a prior infant with GBS disease, or unknown status with risk factors (fever, membranes ruptured 18+ hours, or preterm labor). Penicillin is first-line; use cefazolin or, per susceptibility, clindamycin/vancomycin for penicillin allergy.

Placenta previa is implantation of the placenta over or near the cervical os, producing classic PAINLESS, bright-red vaginal bleeding. The critical safety rule is to AVOID any digital vaginal or cervical examination, because a finger can perforate or dislodge the placenta over the os and trigger catastrophic hemorrhage. Therefore performing a digital vaginal exam is the action the nurse must avoid. Placental location is confirmed by ultrasound, not by palpation.

Continuous fetal heart rate monitoring with an external monitor is appropriate and necessary to detect fetal compromise from blood loss. Assessing the amount and character of bleeding (pad counts, color, clots) is essential ongoing nursing surveillance. Maintaining bed rest and establishing IV access are correct supportive measures that prepare for possible transfusion or emergency cesarean and reduce activity that could worsen bleeding. None of these three endanger the placenta.

Clinical pearl: 'Previa = no fingers.' Post a sign and ensure no vaginal exams are performed. Contrast this with abruptio placentae, which causes PAINFUL, dark-red bleeding with a rigid, tender, board-like uterus. Both are third-trimester bleeding emergencies: type and crossmatch blood, monitor maternal vital signs and fetal status, count pads/weigh linens to quantify loss, and keep the client NPO in case surgery is needed. Definitive management of significant previa bleeding at term or with instability is cesarean birth.

Magnesium sulfate is given for seizure prophylaxis in preeclampsia, but it is a CNS and neuromuscular depressant with a narrow therapeutic window. Signs of toxicity include respiratory depression, loss of deep tendon reflexes, decreased urine output (which lets magnesium accumulate because it is renally cleared), and a declining level of consciousness. Thus a respiratory rate of 10, absent patellar reflexes, urine output of 20 mL/hr, and increasing drowsiness with slurred speech all signal toxicity—stop the infusion, notify the provider, and prepare calcium gluconate, the antidote.

A respiratory rate of 18 is normal and reassuring, not toxic; the threshold of concern is under 12. Deep tendon reflexes graded 2+ are normal and reassuring (present, intact reflexes indicate the client is not magnesium-toxic); it is the ABSENCE of reflexes that heralds toxicity, because diminishing reflexes are typically the FIRST warning sign before respiratory or cardiac depression.

Clinical pearl: monitor the 'big four' before and during magnesium therapy—respirations (keep 12 or higher), deep tendon reflexes (should be present), urine output (keep at least 30 mL/hr), and level of consciousness—plus continuous fetal monitoring. Keep calcium gluconate at the bedside to reverse toxicity. Therapeutic serum magnesium runs roughly 4 to 7 mEq/L (about 4.8 to 8.4 mg/dL); higher levels progressively cause loss of reflexes, respiratory depression, and cardiac arrest. Memory aid: 'Reflexes gone, respirations low, urine slow, LOC dropping—magnesium's too high, calcium to the rescue.'

Abruptio placentae is premature separation of a normally implanted placenta. Blood collects behind the placenta, irritating and distending the uterus, so the hallmark findings are a rigid, board-like, tender uterus with abdominal PAIN and dark-red bleeding (which may be concealed if the separation is central). Therefore a rigid, board-like, tender uterus with dark-red bleeding most strongly indicates abruption.

Painless onset while resting is characteristic of placenta previa, not abruption; previa bleeding is classically painless. Bright-red bleeding with a soft, nontender abdomen also fits previa—bright red because the blood is fresh from the low-lying placenta over the os, and soft because there is no retroplacental clot irritating the uterus. A reassuring fetal heart rate and normal maternal vital signs do not point to abruption; abruption more often produces fetal distress (late decelerations, bradycardia) and signs of maternal hemorrhage or hypovolemia.

Clinical pearl: think 'previa = painless, bright red, soft uterus, no vaginal exam' versus 'abruption = painful, dark red (or concealed), rigid tender uterus.' Abruption is associated with hypertension, trauma, cocaine use, and prior abruption, and can rapidly cause DIC and fetal death. For either, monitor maternal vitals and fetal status, quantify blood loss, obtain type and crossmatch and coagulation studies, and prepare for possible emergency cesarean. Never perform a digital vaginal exam when previa has not been ruled out.

An Rh-negative mother can become sensitized if fetal Rh-positive blood enters her circulation, producing anti-D antibodies that endanger current and future Rh-positive fetuses (hemolytic disease of the newborn). Rho(D) immune globulin prevents this by binding fetal Rh-positive cells before the mother mounts an immune response. Standard practice is to give RhoGAM routinely at about 28 weeks' gestation and again within 72 hours after delivery of an Rh-positive infant. That makes the statement about a 28-week dose plus a postpartum dose for an Rh-positive infant correct.

Giving RhoGAM only if the newborn is Rh-negative is wrong—reversed logic. RhoGAM is indicated when the infant is Rh-POSITIVE; if the newborn is Rh-negative, there is no D antigen to sensitize the mother and the postpartum dose is not needed. Giving RhoGAM to the newborn is wrong; it is administered to the mother, not the baby. Saying it is unnecessary in a first pregnancy is wrong and a common misconception: sensitization can occur during the first pregnancy from any fetomaternal hemorrhage, which is exactly why the routine 28-week dose exists.

Clinical pearl: also give RhoGAM after any potential sensitizing event—miscarriage or abortion at 12 weeks or later (before 12 weeks, ACOG now individualizes the decision), ectopic pregnancy, amniocentesis, abdominal trauma, chorionic villus sampling, or antepartum bleeding. Remember: RhoGAM prevents sensitization; it does nothing for a mother who is ALREADY sensitized (positive antibody screen).

Prenatal screening is timing-driven. Correct statements: the Group B strep culture is collected at 36 to 37 weeks (results guide intrapartum antibiotic prophylaxis); the 1-hour glucose challenge screens for gestational diabetes at 24 to 28 weeks; blood type, Rh, and antibody screen are part of first-visit labs (along with CBC, rubella, hepatitis B, HIV, and STI testing); and a positive/abnormal 1-hour glucose challenge is followed by the diagnostic 3-hour glucose tolerance test.

The statement that the quad/maternal serum screen is not offered until 36 weeks is inaccurate—the maternal serum AFP/quad screen (for neural tube defects and aneuploidy) is a SECOND-trimester test, typically drawn around 15 to 22 weeks; at 36 weeks it would be far too late to act on. The statement that RhoGAM is given to all Rh-POSITIVE mothers at 28 weeks is inaccurate on two counts: RhoGAM is for Rh-NEGATIVE mothers, and Rh-positive women never need it because they already carry the D antigen.

Clinical pearl: anchor tests to trimesters. FIRST visit: blood type/Rh/antibody screen, CBC, rubella, hepatitis B, HIV, STIs, urinalysis. SECOND trimester (about 15 to 22 weeks): quad screen and anatomy ultrasound. 24 to 28 weeks: 1-hour glucose challenge (then 3-hour GTT if elevated) and the routine RhoGAM dose for Rh-negative mothers. 36 to 37 weeks: Group B strep culture. Knowing the 'when' lets you catch questions that pair the right test with the wrong week.