2026 Maternity Nursing Clinical Judgment Case
Studies Practice Questions Answer Rationales
Pregnancy Cues Labor Priorities Maternal Fetal
Nursing Decisions
SECTION 1: PREGNANCY CUES AND ASSESSMENT (Questions 1–40)
1. A client at 10 weeks' gestation reports breast tenderness, nausea, and
frequent urination. Which classification do these findings represent?
A. Presumptive cues of pregnancy
B. Probable cues of pregnancy
C. Positive cues of pregnancy
D. Diagnostic cues of pregnancy
Answer: A
Rationale: Presumptive cues are subjective symptoms reported by the client that
suggest pregnancy but can have other causes. These include amenorrhea, nausea,
breast tenderness, frequent urination, and fatigue. Probable cues are objective
findings noted by the examiner. Positive cues are definitive evidence of pregnancy
(e.g., fetal heart tones, ultrasound visualization).
2. A nurse notes Chadwick's sign during a pelvic examination. This finding is
classified as:
A. Presumptive cue
B. Probable cue
C. Positive cue
D. Diagnostic cue
Answer: B
,Rationale: Chadwick's sign (bluish-purple discoloration of the cervix, vagina, and
vulva) is a probable cue of pregnancy because it is an objective finding noted by
the examiner. Probable cues also include Goodell's sign, Hegar's sign, and a
positive pregnancy test.
3. A client at 8 weeks' gestation has a positive serum beta-hCG test. This
finding is classified as:
A. Presumptive cue
B. Probable cue
C. Positive cue
D. Subjective cue
Answer: B
Rationale: A positive pregnancy test (serum or urine hCG) is a probable cue, not a
positive cue. Positive cues include fetal heart tones auscultated by Doppler, fetal
movement felt by the examiner, and ultrasound visualization of the fetus.
4. Which finding is considered a positive cue of pregnancy?
A. Amenorrhea
B. Nausea and vomiting
C. Fetal heart tones detected by Doppler
D. Breast tenderness
Answer: C
Rationale: Positive cues are definitive evidence of pregnancy and include fetal
heart tones detected by Doppler, fetal movement palpated by the examiner, and
ultrasound visualization of the fetus. Amenorrhea, nausea, and breast tenderness
are presumptive cues.
,5. A nurse is assessing a client at 12 weeks' gestation. Which finding would the
nurse expect related to Hegar's sign?
A. Bluish discoloration of the cervix
B. Softening of the uterine isthmus
C. Softening of the cervix
D. Enlargement of the uterus
Answer: B
Rationale: Hegar's sign is the softening and compressibility of the lower uterine
segment (isthmus) around 6–12 weeks' gestation. Chadwick's sign is bluish
discoloration. Goodell's sign is softening of the cervix.
6. A client at 16 weeks' gestation reports feeling fetal movement for the first
time. This is known as:
A. Quickening
B. Lightening
C. Ballottement
D. Braxton Hicks contractions
Answer: A
Rationale: Quickening is the first perception of fetal movement by the mother,
typically felt between 16–20 weeks' gestation in primigravidas. Lightening is the
descent of the fetus into the pelvis. Ballottement is a passive fetal movement felt
on examination.
7. A nurse is assessing a client at 20 weeks' gestation. Which finding would the
nurse document as a probable cue?
A. Fetal heart tones heard with a fetoscope
B. Client reports of fetal movement
C. Braxton Hicks contractions
D. Positive urine pregnancy test
, Answer: C
Rationale: Braxton Hicks contractions are probable cues because they are
objective findings noted by the examiner. Fetal heart tones heard with a fetoscope
are positive cues. Client reports of fetal movement are presumptive. A positive
urine pregnancy test is a probable cue but is not the best answer here.
8. A client at 6 weeks' gestation reports fatigue, breast tenderness, and
amenorrhea. Which cue classification is most appropriate?
A. Positive
B. Probable
C. Presumptive
D. Diagnostic
Answer: C
Rationale: Fatigue, breast tenderness, and amenorrhea are subjective symptoms
reported by the client, making them presumptive cues. They suggest pregnancy but
can have other causes.
9. A nurse is performing a pelvic examination on a client at 8 weeks' gestation.
The nurse notes a softened cervix. This finding is known as:
A. Chadwick's sign
B. Hegar's sign
C. Goodell's sign
D. Ballottement
Answer: C
Rationale: Goodell's sign is the softening of the cervix that occurs around 6–8
weeks' gestation. Chadwick's sign is bluish discoloration. Hegar's sign is softening
of the uterine isthmus.
Studies Practice Questions Answer Rationales
Pregnancy Cues Labor Priorities Maternal Fetal
Nursing Decisions
SECTION 1: PREGNANCY CUES AND ASSESSMENT (Questions 1–40)
1. A client at 10 weeks' gestation reports breast tenderness, nausea, and
frequent urination. Which classification do these findings represent?
A. Presumptive cues of pregnancy
B. Probable cues of pregnancy
C. Positive cues of pregnancy
D. Diagnostic cues of pregnancy
Answer: A
Rationale: Presumptive cues are subjective symptoms reported by the client that
suggest pregnancy but can have other causes. These include amenorrhea, nausea,
breast tenderness, frequent urination, and fatigue. Probable cues are objective
findings noted by the examiner. Positive cues are definitive evidence of pregnancy
(e.g., fetal heart tones, ultrasound visualization).
2. A nurse notes Chadwick's sign during a pelvic examination. This finding is
classified as:
A. Presumptive cue
B. Probable cue
C. Positive cue
D. Diagnostic cue
Answer: B
,Rationale: Chadwick's sign (bluish-purple discoloration of the cervix, vagina, and
vulva) is a probable cue of pregnancy because it is an objective finding noted by
the examiner. Probable cues also include Goodell's sign, Hegar's sign, and a
positive pregnancy test.
3. A client at 8 weeks' gestation has a positive serum beta-hCG test. This
finding is classified as:
A. Presumptive cue
B. Probable cue
C. Positive cue
D. Subjective cue
Answer: B
Rationale: A positive pregnancy test (serum or urine hCG) is a probable cue, not a
positive cue. Positive cues include fetal heart tones auscultated by Doppler, fetal
movement felt by the examiner, and ultrasound visualization of the fetus.
4. Which finding is considered a positive cue of pregnancy?
A. Amenorrhea
B. Nausea and vomiting
C. Fetal heart tones detected by Doppler
D. Breast tenderness
Answer: C
Rationale: Positive cues are definitive evidence of pregnancy and include fetal
heart tones detected by Doppler, fetal movement palpated by the examiner, and
ultrasound visualization of the fetus. Amenorrhea, nausea, and breast tenderness
are presumptive cues.
,5. A nurse is assessing a client at 12 weeks' gestation. Which finding would the
nurse expect related to Hegar's sign?
A. Bluish discoloration of the cervix
B. Softening of the uterine isthmus
C. Softening of the cervix
D. Enlargement of the uterus
Answer: B
Rationale: Hegar's sign is the softening and compressibility of the lower uterine
segment (isthmus) around 6–12 weeks' gestation. Chadwick's sign is bluish
discoloration. Goodell's sign is softening of the cervix.
6. A client at 16 weeks' gestation reports feeling fetal movement for the first
time. This is known as:
A. Quickening
B. Lightening
C. Ballottement
D. Braxton Hicks contractions
Answer: A
Rationale: Quickening is the first perception of fetal movement by the mother,
typically felt between 16–20 weeks' gestation in primigravidas. Lightening is the
descent of the fetus into the pelvis. Ballottement is a passive fetal movement felt
on examination.
7. A nurse is assessing a client at 20 weeks' gestation. Which finding would the
nurse document as a probable cue?
A. Fetal heart tones heard with a fetoscope
B. Client reports of fetal movement
C. Braxton Hicks contractions
D. Positive urine pregnancy test
, Answer: C
Rationale: Braxton Hicks contractions are probable cues because they are
objective findings noted by the examiner. Fetal heart tones heard with a fetoscope
are positive cues. Client reports of fetal movement are presumptive. A positive
urine pregnancy test is a probable cue but is not the best answer here.
8. A client at 6 weeks' gestation reports fatigue, breast tenderness, and
amenorrhea. Which cue classification is most appropriate?
A. Positive
B. Probable
C. Presumptive
D. Diagnostic
Answer: C
Rationale: Fatigue, breast tenderness, and amenorrhea are subjective symptoms
reported by the client, making them presumptive cues. They suggest pregnancy but
can have other causes.
9. A nurse is performing a pelvic examination on a client at 8 weeks' gestation.
The nurse notes a softened cervix. This finding is known as:
A. Chadwick's sign
B. Hegar's sign
C. Goodell's sign
D. Ballottement
Answer: C
Rationale: Goodell's sign is the softening of the cervix that occurs around 6–8
weeks' gestation. Chadwick's sign is bluish discoloration. Hegar's sign is softening
of the uterine isthmus.
