Saint Mary’s University

SCHOOL OF HEALTH and NATURAL SCIENCES

Nursing Department
Bayombong, Nueva Vizcaya

EVALUATION TOOL FOR PRENATAL ASSESSMENT

Name: ______________________________________________________ Section: _____________ Group:________

DIRECTIONS: Below is a list of criteria to evaluate the student’s skill in Prenatal Assessment. Indicate your evaluation by
placing the number of score on the appropriate column using the following descriptive scale.

0- Not Done 1- Done Incorrectly 2- Done Correctly

PROCEDURES 0 1 2 REMARKS
1. Greets the pregnant mother and establish rapport
2. Introduce his/herself
3. Informs pregnant woman of the procedure
4. Explains to the mother the importance/ significance of the
procedure
5. Provides privacy to mother by screening or closing the door of
examination room
6. Obtains complete demographic data
6.1 Name
6.2 Age
6.3 Address
6.4 Religion
6.5 Marital Status
6.6 Educational Attainment
6.7 Occupation
6.8 Telephone Number
6.9 Weight and Height
6.10 Obtains her SO’s profiles
7. Asks mother her chief concern
7.1 Date of last menstrual period
7.2 Pregnancy test
7.3 Signs of early pregnancy
7.4 Discomforts
7.5 Danger signs
7.6 Ask if the pregnancy is planned
8. Obtains pregnant mothers past history of illness
9. Obtains pregnant mothers family history
10. Obtains pregnant mothers present history of illness
10.1 Obtains day history or social profiles
10.2 Current nutrition, elimination, pattern, sleep, recreation and
interpersonal interaction
10.3 Type and frequency of exercise and hobbies
10.4 Smoking, alcohol, and drug abuse
10.5 Medication History
11. Obtains gynecologic history
11.1 Age of menarche, thelarche, and coitarche
11.2 Menstrual cycle
11.3 Past surgeries of the reproductive tract
11.4 Family planning method used
11.5 sexual history
11.6 stress incontinence
12. Obtains obstetric history
12.1 Previous pregnancies (GP, TPAL/M)
12.2 Previous cesarean section
12.3 History of abortion
12.4 History of stillbirth
12.5 History of postpartum hemorrhage
13. Performs general examination
13.1 Vital signs
13.2 Abdominal examination (inspection: scars and shape, fundal
height, palpation [Leopold’s maneuver], auscultation [FHT] )
13.3 Laboratory test results
14. Determine emergency plans, place of delivery
15. Identifies any deviation from normal
16. Documents the data and procedures done
TOTAL
AVERAGE

Comments:_________________________________________________________________________________________
__________________________________________________________________________________________________
_______________________.

Student’s signature over printed name/ Date/ Time:

__________________________________________________________

Clinical Instructor’s signature over printed name/ Date/Time:___________________________________