FOUNDATIONS OF MATERNAL-
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1) Clinical Judgment and the Nursing Process
Reference: Ch. 1 — Clinical Judgment and the Nursing Process
Stem:
A pregnant client at 34 weeks’ gestation arrives at the clinic
reporting mild ankle swelling and fatigue. The licensed practical
nurse (LPN) notes a blood pressure of 148/94 mm Hg and urine
dipstick protein of 2+. The client says, “I thought swelling was
normal in pregnancy.” What is the nurse’s best action?
,Options:
A. Reassure the client that these findings are expected in late
pregnancy
B. Encourage the client to increase fluid intake and rest at home
C. Notify the RN or provider promptly about possible
preeclampsia
D. Ask the client to return in 2 weeks for a repeat blood
pressure
Correct Answer: C
Rationale — Correct Answer:
These findings are abnormal and suggest possible preeclampsia,
which requires prompt follow-up. The LPN should recognize the
abnormal assessment and report it immediately to the RN or
provider. Early reporting supports maternal and fetal safety.
Rationale — Incorrect Options:
A. Swelling alone may occur in pregnancy, but elevated blood
pressure and proteinuria are not expected.
B. Rest and fluids do not address the possible hypertensive
disorder and could delay care.
D. Waiting 2 weeks could place the client at risk for worsening
complications.
Teaching Point:
Elevated blood pressure plus proteinuria in pregnancy requires
immediate reporting.
,Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Ch. 1.
2) Clinical Judgment and the Nursing Process
Reference: Ch. 1 — Clinical Judgment and the Nursing Process
Stem:
A postpartum client is 6 hours after a vaginal birth. The LPN
finds the fundus firm and midline, lochia rubra moderate, and
bladder non-distended. Which finding should the nurse report
first?
Options:
A. The client states she is tired and wants to sleep
B. The client has a temperature of 100.0°F (37.8°C)
C. The client’s lochia is moderate and rubra
D. The client asks for help breastfeeding
Correct Answer: B
Rationale — Correct Answer:
A temperature of 100.0°F is not always abnormal after birth,
but fever can signal infection or another complication if it
persists or rises. The LPN should report abnormal postpartum
assessment findings promptly for further evaluation. The other
findings are expected or routine.
Rationale — Incorrect Options:
A. Fatigue is common after labor and birth.
, C. Moderate rubra lochia is expected in the early postpartum
period.
D. Breastfeeding assistance is appropriate and expected care.
Teaching Point:
Report postpartum findings that may signal infection or
deterioration.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Ch. 1.
3) Safety and Quality Within Women’s Health
Reference: Ch. 1 — Safety and Quality Within Women’s Health
Stem:
During medication administration on the labor unit, the LPN is
preparing to give an oxytocin infusion to a client whose arm
band is missing. The client says her name and room number
match the medication record. What should the nurse do first?
Options:
A. Administer the medication because the client verbally
identified herself
B. Ask another nurse to verify the client’s identity before giving
the medication
C. Hold the medication and replace the client’s arm band later
D. Document the medication as delayed and continue with
other tasks
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1) Clinical Judgment and the Nursing Process
Reference: Ch. 1 — Clinical Judgment and the Nursing Process
Stem:
A pregnant client at 34 weeks’ gestation arrives at the clinic
reporting mild ankle swelling and fatigue. The licensed practical
nurse (LPN) notes a blood pressure of 148/94 mm Hg and urine
dipstick protein of 2+. The client says, “I thought swelling was
normal in pregnancy.” What is the nurse’s best action?
,Options:
A. Reassure the client that these findings are expected in late
pregnancy
B. Encourage the client to increase fluid intake and rest at home
C. Notify the RN or provider promptly about possible
preeclampsia
D. Ask the client to return in 2 weeks for a repeat blood
pressure
Correct Answer: C
Rationale — Correct Answer:
These findings are abnormal and suggest possible preeclampsia,
which requires prompt follow-up. The LPN should recognize the
abnormal assessment and report it immediately to the RN or
provider. Early reporting supports maternal and fetal safety.
Rationale — Incorrect Options:
A. Swelling alone may occur in pregnancy, but elevated blood
pressure and proteinuria are not expected.
B. Rest and fluids do not address the possible hypertensive
disorder and could delay care.
D. Waiting 2 weeks could place the client at risk for worsening
complications.
Teaching Point:
Elevated blood pressure plus proteinuria in pregnancy requires
immediate reporting.
,Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Ch. 1.
2) Clinical Judgment and the Nursing Process
Reference: Ch. 1 — Clinical Judgment and the Nursing Process
Stem:
A postpartum client is 6 hours after a vaginal birth. The LPN
finds the fundus firm and midline, lochia rubra moderate, and
bladder non-distended. Which finding should the nurse report
first?
Options:
A. The client states she is tired and wants to sleep
B. The client has a temperature of 100.0°F (37.8°C)
C. The client’s lochia is moderate and rubra
D. The client asks for help breastfeeding
Correct Answer: B
Rationale — Correct Answer:
A temperature of 100.0°F is not always abnormal after birth,
but fever can signal infection or another complication if it
persists or rises. The LPN should report abnormal postpartum
assessment findings promptly for further evaluation. The other
findings are expected or routine.
Rationale — Incorrect Options:
A. Fatigue is common after labor and birth.
, C. Moderate rubra lochia is expected in the early postpartum
period.
D. Breastfeeding assistance is appropriate and expected care.
Teaching Point:
Report postpartum findings that may signal infection or
deterioration.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Ch. 1.
3) Safety and Quality Within Women’s Health
Reference: Ch. 1 — Safety and Quality Within Women’s Health
Stem:
During medication administration on the labor unit, the LPN is
preparing to give an oxytocin infusion to a client whose arm
band is missing. The client says her name and room number
match the medication record. What should the nurse do first?
Options:
A. Administer the medication because the client verbally
identified herself
B. Ask another nurse to verify the client’s identity before giving
the medication
C. Hold the medication and replace the client’s arm band later
D. Document the medication as delayed and continue with
other tasks
