Ateneo de Zamboanga University

College of Nursing
PERFORMANCE EVALUATION CHECKLIST
PREPARING A CLIENT FOR A PREGNANCY TEST

Name of Student: __________________________ Date Performed: ___________________

Level & Section: ____________________
Legend (Rating Criteria):
5 – Expert (student performs all tasks proficiently and independently).
4 – Competent (student performs efficiently in an effective and efficient manner).
3 – Progress Acceptable (performance is usually effective and but not always).
2 – Needs Improvement (progress in performance is too slow to judge satisfactorily; task performance
is not most of the time).
1 – Progress Unacceptable (no progress in performance has been demonstrated, and or performance
is consistently ineffective and inefficient).
A Pregnancy test attempts to determine whether a woman is pregnant. All pregnancy tests work by
detecting a certain hormone in the urine or blood that is only there when a woman is pregnant. The
hormone is called human chorionic gonadotropin or HCG. It is also called the pregnancy hormone.

PROCEDURE 1 2 3 4 5
1. Explain the procedure
2. Collect the first-voided urine, including the “first stream”
urine
in the morning using a clean, dry bottle free of
detergents or
contaminants.
 There is no need for a sterile specimen container
if it is
to be used in simple pregnancy testing.

3. Do not drink fluids from 8pm the night before to concentrate

the urine.
 Concentrated urine yields best results; diluted
urine
may result in a false negative result.

4. Refrain from taking any drug 24 hours before the test.

 Some drugs such as aspirin, barbiturates,
antidepressants, phenothiazine and
anticonvulsants cause a false positive result. The
presence of protein and blood in the urine may
also yield a false positive.

5. Label the specimen with the woman’s name, date and time
of voiding.
6. Bring the specimen to the laboratory immediately.
77 Refrigerate urine specimen if more than one hour is to pass
. before the specimen gets to the laboratory because
room temperature is high enough to destroy HCG.

TOTAL
__________________________
Clinical Instructor
(Sign over printed name)