Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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Chapter 01: Maternity and Women’s Health Care Today
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Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition L
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MULTIPLE CHOICE L
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1. A nurse educator is teaching a group of nursing students about the history of family-centered
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Tmaternity care. Which statement should the nurse include in the teaching session? T L T L L
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a. The Sheppard-Towner Act of 1921 promoted family-centered care.
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b. Changes in pharmacologic management of labor prompted family-centered care. L
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c. Demands by physicians for family involvement in childbirth increased the practice L
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of family-centered care.
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d. Parental requests that infants be allowed to remain with them rather than in a L
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nursery initiated the practice of family-centered care.
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As research began to identify the benefits of early, extended parent–infant contact, parents
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Tbegan to insist that the infant remain with them. This gradually developed into the practice of
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Trooming-in and finally to family-centered maternity care. The Sheppard-Towner Act provided T L T L T L L
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Tfunds for state-managed programs for mothers and children but did not promote
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family-centered care. The changes in pharmacologic management of labor were not a factor in L
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Tfamily-centered maternity care. Family-centered care was a request by parents, not physicians. L
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DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L T L T L T L L
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Planning MSC: Patient Needs: Health Promotion and Maintenance
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2. Expectant parents ask a prenatal nurse educator, “Which setting for childbirth limits the
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amount of parent–infant int eracUt io nS?” N
WhT Oer should the nurse provide for these
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ich answ
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parents in order to assist them in choosing an appropriate birth setting?
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a. Birth center T L
b. Home birth T L
c. Traditional hospital birth T L T L
d. Labor, birth, and recovery room L
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In the traditional hospital setting, the mother may see the infant for only short feeding periods,
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Tand the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in
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Tparent–infant contact. Home births allow the greatest amount of parent–infant contact. The L
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Tlabor, birth, recovery, and postpartum room setting allows for increased parent–infant contact.
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DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L T L T L T L L
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Planning MSC: Patient Needs: Health Promotion and Maintenance
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3. Which statement best describes the advantage of a labor, birth, recovery, and postpartum
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(LDRP) room?
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a. The family is in a familiar environment. T L T L L
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b. They are less expensive than traditional hospital rooms. T L T L L
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c. The infant is removed to the nursery to allow the mother to rest.
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d. The woman’s support system is encouraged to stay until discharge.
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ANS: T L D
NURSINGTB.COM
,Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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Sleeping equipment is provided in a private room. A hospital setting is never a familiar
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Tenvironment to new parents. An LDRP room is not less expensive than a traditional hospital T L L
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Troom. The baby remains with the mother at all times and is not removed to the nursery for
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routine care or testing. The father or other designated members of the mother’s support system
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Tare encouraged to stay at all times.
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DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L T L T L T L L
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Assessment MSC: Patient Needs: Health Promotion and Maintenance
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4. Which nursing intervention is an independent function of the professional nurse?
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a. Administering oral analgesics L
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b. Requesting diagnostic studies T L T L
c. Teaching the patient perineal care L
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d. Providing wound care to a surgical incision T L L
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ANS: T L C
Nurses are now responsible for various independent functions, including teaching, counseling,
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and intervening in nonmedical problems. Interventions initiated by the physician and carried
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out by the nurse are called dependent functions. Administrating oral analgesics is a dependent
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function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic
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Tstudies is a dependent function. Providing wound care is a dependent function; however, the
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physician prescribes the type of wound care through direct orders or protocol.
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DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L T L T L T L L
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Assessment MSC: Patient Needs: Safe and Effective Care Environment
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5. Which response by the nurse is the most therapeutic when the patient states, “I’m so afraid to
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have a cesarean birth”? L
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NURSINGTB.COM
a. “Everything will be OK.” T L L
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b. “Don’t worry about it. It will be over soon.” L
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c. “What concerns you most about a cesarean birth?” L
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d. “The physician will be in later and you can talk to him.”
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ANS: T L C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is
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Tsaying and asks for clarification, which is the most therapeutic response. The response,
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“Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about T L L
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Tit. It will be over soon” will indicate that the patient’s feelings are not important. The
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response, “The physician will be in later and you can talk to him” does not allow the patient to
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Tverbalize her feelings when she wishes to do that. T L T L T L T L L
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DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L T L T L T L L
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Implementation MSC: Patient Needs: Psychosocial Integrity
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6. In which step of the nursing process does the nurse determine the appropriate interventions for
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the identified nursing diagnosis?
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a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: T L A
NURSINGTB.COM
,Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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The third step in the nursing process involves planning care for problems that were identified during
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assessment. The evaluation phase is determining whether the goals have been met.
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During the assessment phase, data are collected. The intervention phase is when the plan of care
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is carried out.
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DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L L
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Planning MSC: Patient Needs: Safe and Effective Care Environment
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7. Which goal is most appropriate for the collaborative problem of wound infection?
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a. The patient will not exhibit further signs of infection.
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b. Maintain the patient’s fluid intake at 1000 mL/8 hour. L
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c. The patient will have a temperature of 98.6F within 2 days.
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d. Monitor the patient to detect therapeutic response to antibiotic therapy. L
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ANS: T L D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
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Tinterventions of monitoring or observing. Monitoring for complications such as further signs T L L
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Tof infection is an independent nursing role. Intake and output is an independent nursing role.
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TMonitoring a patient’s temperature is an independent nursing role. L
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DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L L
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Planning MSC: Patient Needs: Safe and Effective Care Environment
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8. Which nursing intervention is written correctly?
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a. Force fluids as necessary. L
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b. Observe interaction with the infant. L
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c. Encourage turning, coughing, and deep breathing. L
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d. Assist to ambulate for 10NmUinRuS
teIat G
sN 8TAB
M., C
2OM, and 6 PM.
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ANS: T L D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is not T L L
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specific; it does not state how much or how often. Encouraging the patient to turn, cough, and
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Tbreathe deeply is not detailed or specific. Observing interaction with the infant does not state
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Thow often this procedure should be done. Assisting the patient to ambulate for 10 minutes
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Twithin a certain timeframe is specific.L
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Planning MSC: Patient Needs: Safe and Effective Care Environment
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9. The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which
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response by the nurse would be the most therapeutic?
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a. “You’re afraid to take the baby home?” L
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b. “Don’t you have a mother who can come and help?” L
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c. “You should read the literature I gave you before you leave.”L
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d. “I was scared when I took my first baby home, but everything worked out.”
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ANS: T L A
NURSINGTB.COM
, Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
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This response uses reflection to show concern and open communication. The other choices are
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blocks to communication. Asking if the patient has a mother who can come and assist blocks
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further communication with the patient. Telling the patient to read the literature before leaving does
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not allow the patient to express her feelings further. Sharing your own birth experience is
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inappropriate.
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Implementation MSC: Patient Needs: Psychosocial Integrity
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10. The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
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tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
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of 10. Which expected outcome is correctly stated for this problem?
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a. Patient will state that pain is a 2 on a scale of 10. T L L
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b. Patient will have a reduction in pain after administration of the prescribed L
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analgesic. T L
c. Patient will state an absence of pain 1 hour after administration of the prescribed L
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analgesic. T L
d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
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the prescribed analgesic.
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ANS: T L D
The outcome should be patient-centered, measurable, realistic, and attainable and within a
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specified timeframe. Patient stating that her pain is now 2 on a scale of 10 lacks a timeframe. Patient
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having a reduction in pain after administration of the prescribed analgesic lacks a measurement.
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Patient stating an absence of pain 1 hour after the administration of prescribed analgesic is
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unrealistic.
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o n S N OTB J : NuOr s ing Process Step: T L T L
N R I G B .C M T L T L
Planning MSC: Patient Needs: Physiologic Integrity
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11. Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
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a. Risk for anxiety related to upcoming birth L
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b. Risk for imbalanced nutrition related to NPO status L
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c. Risk for altered family processes related to new addition to the family
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d. Risk for injury (maternal) related to altered sensations and positional or physical
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ANS: T L D
The nurse should determine which problem needs immediate attention. Risk for injury is the
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problem that has the priority at this time because it is a safety problem. Risk for anxiety,
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imbalanced nutrition, and altered family processes are not the priorities at this time.
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DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L L
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Implementation MSC: Patient Needs: Safe and Effective Care Environment
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12. Regarding advanced roles of nursing, which statement related to clinical practice is the most
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accurate?
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a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital L
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setting. T L
b. Clinical nurse specialists (CNSs) provide primary care to obstetric patients. L
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c. Neonatal nurse practitioners provide emergency care in the postbirth setting to L
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Chapter 01: Maternity and Women’s Health Care Today
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Foundations of Maternal-Newborn & Women’s Health Nursing, 7th Edition L
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MULTIPLE CHOICE L
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1. A nurse educator is teaching a group of nursing students about the history of family-centered
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Tmaternity care. Which statement should the nurse include in the teaching session? T L T L L
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a. The Sheppard-Towner Act of 1921 promoted family-centered care.
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b. Changes in pharmacologic management of labor prompted family-centered care. L
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c. Demands by physicians for family involvement in childbirth increased the practice L
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of family-centered care.
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d. Parental requests that infants be allowed to remain with them rather than in a L
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nursery initiated the practice of family-centered care.
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ANS: T L D
As research began to identify the benefits of early, extended parent–infant contact, parents
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Tbegan to insist that the infant remain with them. This gradually developed into the practice of
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Trooming-in and finally to family-centered maternity care. The Sheppard-Towner Act provided T L T L T L L
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T L
T
L
Tfunds for state-managed programs for mothers and children but did not promote
L
T T L T L T L L
T T L T L T L T L T L T L
family-centered care. The changes in pharmacologic management of labor were not a factor in L
T L
T T L L
T T L L
T L
T L
T L
T T L T L L
T T L
L
Tfamily-centered maternity care. Family-centered care was a request by parents, not physicians. L
T T L T L L
T T L L
T L
T T L T L L
T L
T
DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L T L T L T L L
T
Planning MSC: Patient Needs: Health Promotion and Maintenance
L
T L
T T L T L T L L
T T L L
T
2. Expectant parents ask a prenatal nurse educator, “Which setting for childbirth limits the
NRIGB.C M
T L L
T T L L
T L
T T L L
T T L T L T L T L L
T
amount of parent–infant int eracUt io nS?” N
WhT Oer should the nurse provide for these
L L L L L
ich answ
T T T T T
L
T L
T L
T L
T L
T T L L
T L
T L
T L
T T L T L
parents in order to assist them in choosing an appropriate birth setting?
L
T T L T L T L L
T T L T L T L T L T L L
T T L
a. Birth center T L
b. Home birth T L
c. Traditional hospital birth T L T L
d. Labor, birth, and recovery room L
T L
T T L T L
ANS: T L C
In the traditional hospital setting, the mother may see the infant for only short feeding periods,
L
T L
T T L L
T T L L
T L
T L
T T L T L L
T T L L
T L
T L
T
L
Tand the infant is cared for in a separate nursery. Birth centers are set up to allow an increase in
L
T T L L
T T L L
T L
T L
T L
T L
T L
T T L T L T L L
T L
T L
T L
T L
T L
T
L
Tparent–infant contact. Home births allow the greatest amount of parent–infant contact. The L
T L
T T L L
T T L T L L
T L
T T L T L L
T
L
Tlabor, birth, recovery, and postpartum room setting allows for increased parent–infant contact.
L
T L
T L
T L
T L
T T L L
T T L L
T L
T L
T
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L T L T L T L L
T
Planning MSC: Patient Needs: Health Promotion and Maintenance
L
T L
T T L T L T L L
T T L L
T
3. Which statement best describes the advantage of a labor, birth, recovery, and postpartum
L
T T L L
T L
T L
T L
T L
T L
T L
T L
T L
T L
T
(LDRP) room?
L
T L
T
a. The family is in a familiar environment. T L T L L
T L
T L
T T L
b. They are less expensive than traditional hospital rooms. T L T L L
T L
T T L T L T L
c. The infant is removed to the nursery to allow the mother to rest.
T L T L T L T L T L L
T L
T T L L
T T L L
T T L
d. The woman’s support system is encouraged to stay until discharge.
T L L
T L
T T L L
T T L L
T L
T T L
ANS: T L D
NURSINGTB.COM
,Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
T L T L L
T T L L
T T L T L L
T L
T L
T L
T
Sleeping equipment is provided in a private room. A hospital setting is never a familiar
T L L
T T L T L T L L
T L
T T L L
T T L L
T T L L
T T L
L
Tenvironment to new parents. An LDRP room is not less expensive than a traditional hospital T L L
T L
T L
T T L L
T L
T L
T L
T L
T L
T L
T L
T L
T
L
Troom. The baby remains with the mother at all times and is not removed to the nursery for
L
T L
T T L L
T T L T L L
T L
T T L T L T L T L L
T T L L
T L
T T L
routine care or testing. The father or other designated members of the mother’s support system
L
T L
T L
T L
T L
T T L L
T T L L
T L
T T L L
T L
T T L
L
Tare encouraged to stay at all times.
L
T L
T T L T L L
T T L
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L T L T L T L L
T
Assessment MSC: Patient Needs: Health Promotion and Maintenance
L
T T L T L T L L
T T L T L T L
4. Which nursing intervention is an independent function of the professional nurse?
L
T T L T L T L T L L
T L
T L
T T L T L
a. Administering oral analgesics L
T T L
b. Requesting diagnostic studies T L T L
c. Teaching the patient perineal care L
T T L L
T T L
d. Providing wound care to a surgical incision T L L
T L
T L
T T L L
T
ANS: T L C
Nurses are now responsible for various independent functions, including teaching, counseling,
T L T L L
T T L L
T L
T L
T T L L
T L
T
and intervening in nonmedical problems. Interventions initiated by the physician and carried
L
T T L L
T T L T L T L T L T L T L T L T L L
T
out by the nurse are called dependent functions. Administrating oral analgesics is a dependent
L
T L
T L
T T L L
T L
T T L L
T T L T L T L T L L
T L
T
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic
L
T T L T L L
T L
T T L T L T L L
T T L L
T L
T T L T L T L
Tstudies is a dependent function. Providing wound care is a dependent function; however, the
L T L L
T T L T L T L T L T L T L T L L
T T L T L T L
physician prescribes the type of wound care through direct orders or protocol.
L
T T L T L L
T L
T L
T T L T L L
T T L L
T L
T
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L T L T L T L L
T
Assessment MSC: Patient Needs: Safe and Effective Care Environment
L
T T L T L T L L
T T L L
T T L T L
5. Which response by the nurse is the most therapeutic when the patient states, “I’m so afraid to
T L L
T L
T T L L
T L
T T L T L L
T T L L
T L
T L
T L
T L
T T L
have a cesarean birth”? L
T L
T T L
NURSINGTB.COM
a. “Everything will be OK.” T L L
T T L
b. “Don’t worry about it. It will be over soon.” L
T T L L
T T L T L T L L
T T L
c. “What concerns you most about a cesarean birth?” L
T L
T T L L
T L
T L
T T L
d. “The physician will be in later and you can talk to him.”
T L L
T T L L
T T L L
T T L L
T T L T L L
T
ANS: T L C
The response, “What concerns you most about a cesarean birth” focuses on what the patient is
T L T L L
T L
T L
T T L L
T L
T L
T L
T L
T T L L
T L
T L
T
L
Tsaying and asks for clarification, which is the most therapeutic response. The response,
T L L
T T L L
T L
T T L L
T T L L
T T L T L T L
“Everything will be ok” is belittling the patient’s feelings. The response, “Don’t worry about T L L
T L
T T L T L L
T L
T T L L
T L
T L
T T L L
T
L
Tit. It will be over soon” will indicate that the patient’s feelings are not important. The
T L L
T L
T T L T L T L T L L
T T L T L L
T T L T L L
T L
T
response, “The physician will be in later and you can talk to him” does not allow the patient to
L
T L
T T L T L L
T L
T L
T L
T L
T T L L
T L
T L
T L
T T L L
T L
T T L
L
Tverbalize her feelings when she wishes to do that. T L T L T L T L L
T T L L
T L
T
DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L T L T L T L L
T
Implementation MSC: Patient Needs: Psychosocial Integrity
L
T T L T L T L L
T T L
6. In which step of the nursing process does the nurse determine the appropriate interventions for
L
T T L L
T T L L
T L
T T L L
T T L L
T L
T L
T L
T L
T
the identified nursing diagnosis?
L
T L
T L
T L
T
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: T L A
NURSINGTB.COM
,Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
T L T L L
T T L L
T T L L
T L
T L
T L
T L
T
The third step in the nursing process involves planning care for problems that were identified during
T L T L L
T L
T T L T L L
T T L T L L
T L
T T L L
T L
T L
T
assessment. The evaluation phase is determining whether the goals have been met.
L
T L
T T L T L L
T T L T L T L L
T L
T T L L
T
During the assessment phase, data are collected. The intervention phase is when the plan of care
L
T T L L
T T L L
T L
T T L T L L
T T L T L T L L
T L
T T L
is carried out.
L
T T L T L
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: T L L
T T L L
T L
T
Planning MSC: Patient Needs: Safe and Effective Care Environment
L
T L
T T L T L T L T L T L L
T T L
7. Which goal is most appropriate for the collaborative problem of wound infection?
T L L
T T L L
T L
T L
T T L L
T L
T L
T T L
a. The patient will not exhibit further signs of infection.
L
T T L L
T L
T T L L
T T L L
T
b. Maintain the patient’s fluid intake at 1000 mL/8 hour. L
T L
T L
T L
T L
T L
T L
T T L
c. The patient will have a temperature of 98.6F within 2 days.
L
T T L T L L
T L
T L
T T L T L L
T T L
d. Monitor the patient to detect therapeutic response to antibiotic therapy. L
T L
T T L T L L
T T L L
T L
T L
T
ANS: T L D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
T L L
T T L T L T L T L T L L
T L
T L
T L
T T L
L
Tinterventions of monitoring or observing. Monitoring for complications such as further signs T L L
T L
T T L L
T L
T L
T T L L
T T L L
T
L
Tof infection is an independent nursing role. Intake and output is an independent nursing role.
T L L
T L
T L
T T L L
T T L L
T L
T L
T L
T T L T L L
T
L
TMonitoring a patient’s temperature is an independent nursing role. L
T T L T L L
T L
T T L L
T L
T
DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L L
T T L L
T L
T
Planning MSC: Patient Needs: Safe and Effective Care Environment
L
T L
T T L T L T L T L T L L
T T L
8. Which nursing intervention is written correctly?
T L L
T T L T L L
T
a. Force fluids as necessary. L
T T L L
T
b. Observe interaction with the infant. L
T T L T L T L
c. Encourage turning, coughing, and deep breathing. L
T T L L
T T L T L
d. Assist to ambulate for 10NmUinRuS
teIat G
sN 8TAB
M., C
2OM, and 6 PM.
PM L
T L
T L
T L
T L
T L
T L
T T L L
T L
T
ANS: T L D
Interventions might not be carried out if they are not detailed and specific. “Force fluids” is not T L L
T L
T L
T L
T T L L
T T L T L T L T L T L T L L
T T L L
T
specific; it does not state how much or how often. Encouraging the patient to turn, cough, and
L
T L
T T L T L T L L
T L
T L
T T L L
T T L L
T L
T T L L
T L
T T L
L
Tbreathe deeply is not detailed or specific. Observing interaction with the infant does not state
L
T T L T L L
T T L T L T L T L T L L
T T L L
T L
T L
T
L
Thow often this procedure should be done. Assisting the patient to ambulate for 10 minutes
L
T L
T T L L
T T L T L T L L
T T L T L L
T L
T T L T L
L
Twithin a certain timeframe is specific.L
T T L T L L
T T L
DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L L
T T L L
T L
T
Planning MSC: Patient Needs: Safe and Effective Care Environment
L
T L
T T L T L T L T L T L L
T T L
9. The patient makes the statement: “I’m afraid to take the baby home tomorrow.” Which
T L L
T L
T L
T L
T L
T L
T L
T L
T L
T L
T T L L
T
response by the nurse would be the most therapeutic?
L
T T L T L T L L
T T L T L L
T L
T
a. “You’re afraid to take the baby home?” L
T L
T L
T T L T L T L
b. “Don’t you have a mother who can come and help?” L
T T L L
T L
T T L L
T T L L
T T L
c. “You should read the literature I gave you before you leave.”L
T L
T T L T L T L L
T T L T L T L L
T
d. “I was scared when I took my first baby home, but everything worked out.”
L
T T L T L T L L
T T L T L T L T L T L L
T T L T L
ANS: T L A
NURSINGTB.COM
, Foundations of Maternal-Newborn and Women's Health Nursing 7th Edition Murray Test Bank
T L T L L
T T L T L T L T L L
T L
T L
T L
T
This response uses reflection to show concern and open communication. The other choices are
L
T L
T T L L
T L
T L
T T L L
T L
T L
T L
T L
T L
T
blocks to communication. Asking if the patient has a mother who can come and assist blocks
L
T T L T L T L L
T T L T L L
T T L T L L
T T L T L T L L
T T L
further communication with the patient. Telling the patient to read the literature before leaving does
L
T L
T T L T L L
T L
T T L T L L
T T L L
T L
T T L L
T T L
not allow the patient to express her feelings further. Sharing your own birth experience is
L
T L
T L
T L
T L
T L
T T L L
T L
T L
T L
T T L T L T L L
T
inappropriate.
L
T
DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L L
T T L L
T L
T
Implementation MSC: Patient Needs: Psychosocial Integrity
L
T L
T T L T L L
T T L
10. The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
T L L
T T L T L T L L
T L
T T L T L T L T L T L L
T
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
L
T L
T L
T T L T L L
T L
T T L L
T L
T T L L
T L
T T L L
T L
T L
T
of 10. Which expected outcome is correctly stated for this problem?
L
T T L T L T L L
T L
T T L T L T L T L T L
a. Patient will state that pain is a 2 on a scale of 10. T L L
T L
T L
T L
T T L T L T L T L L
T T L T L
b. Patient will have a reduction in pain after administration of the prescribed L
T T L T L L
T L
T L
T L
T T L L
T L
T L
T
analgesic. T L
c. Patient will state an absence of pain 1 hour after administration of the prescribed L
T T L L
T L
T L
T L
T L
T T L L
T L
T L
T L
T T L
analgesic. T L
d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
T L T L L
T L
T T L L
T L
T T L L
T L
T T L T L L
T L
T L
T L
T T L L
T
the prescribed analgesic.
T L T L T L
ANS: T L D
The outcome should be patient-centered, measurable, realistic, and attainable and within a
T L L
T T L L
T T L T L T L L
T T L T L T L
specified timeframe. Patient stating that her pain is now 2 on a scale of 10 lacks a timeframe. Patient
L
T L
T L
T L
T L
T T L L
T L
T T L L
T L
T L
T L
T L
T L
T L
T L
T T L T L
having a reduction in pain after administration of the prescribed analgesic lacks a measurement.
L
T T L T L T L T L T L T L T L T L T L T L T L T L T L
Patient stating an absence of pain 1 hour after the administration of prescribed analgesic is
L
T L
T L
T L
T L
T T L L
T T L T L L
T L
T L
T L
T T L T L
unrealistic.
L
T
DIF: Cognitive Level: App lic atiU
o n S N OTB J : NuOr s ing Process Step: T L T L
N R I G B .C M T L T L
Planning MSC: Patient Needs: Physiologic Integrity
T L T L T L T L L
T T L
11. Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
L
T T L L
T T L T L L
T T L L
T T L L
T T L L
T L
T T L L
T
a. Risk for anxiety related to upcoming birth L
T L
T T L L
T T L T L
b. Risk for imbalanced nutrition related to NPO status L
T L
T T L L
T L
T L
T L
T
c. Risk for altered family processes related to new addition to the family
L
T L
T L
T T L T L L
T L
T T L L
T L
T L
T
d. Risk for injury (maternal) related to altered sensations and positional or physical
L
T L
T L
T L
T T L L
T L
T L
T L
T L
T L
T
T L changes
ANS: T L D
The nurse should determine which problem needs immediate attention. Risk for injury is the
L
T L
T L
T L
T T L L
T T L L
T T L L
T L
T L
T L
T
problem that has the priority at this time because it is a safety problem. Risk for anxiety,
L
T T L T L T L L
T T L L
T L
T L
T T L T L T L T L L
T T L L
T T L
imbalanced nutrition, and altered family processes are not the priorities at this time.
L
T T L T L T L L
T T L T L L
T T L T L L
T L
T T L
DIF: Cognitive Level: Application OBJ: Nursing Process Step: T L L
T T L L
T L
T
Implementation MSC: Patient Needs: Safe and Effective Care Environment
L
T L
T T L T L L
T T L L
T L
T T L
12. Regarding advanced roles of nursing, which statement related to clinical practice is the most
L
T L
T L
T T L L
T L
T L
T T L L
T L
T L
T L
T L
T
accurate?
L
T
a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital L
T L
T L
T L
T L
T T L L
T T L L
T L
T L
T
setting. T L
b. Clinical nurse specialists (CNSs) provide primary care to obstetric patients. L
T L
T T L L
T T L L
T L
T L
T T L
c. Neonatal nurse practitioners provide emergency care in the postbirth setting to L
T L
T L
T T L L
T L
T T L L
T L
T T L
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