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