FOUNDATIONS OF MATERNAL-
NEWBORN AND WOMEN'S HEALTH
NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
Chapter 1: Clinical Judgment and the Nursing
Process
QUESTION 1
Reference: Clinical Judgment and the Nursing Process —
Components of the Nursing Process
,Clinical Scenario:
A primigravida at 38 weeks gestation is admitted to the labor
and delivery unit in early labor. During the admission
assessment, the nurse notes that the client's blood pressure is
148/92 mm Hg and urine dipstick reveals 2+ protein. The client
reports a headache rated 5 on a 0–10 scale. Which nursing
action demonstrates application of the "Analysis of Cues" step
of the clinical judgment process?
Options:
A. Document the assessment findings in the electronic health
record.
B. Notify the healthcare provider of the elevated blood pressure
and proteinuria.
C. Recognize that these findings may indicate preeclampsia.
D. Administer prescribed antihypertensive medication.
Correct Answer: C. Recognize that these findings may indicate
preeclampsia.
Rationale:
Correct Answer Rationale: Analysis of cues involves
interpreting and clustering assessment findings to identify
patterns and determine their clinical meaning . Recognizing that
elevated blood pressure, proteinuria, and headache may
indicate preeclampsia represents the nurse's analysis of what
these findings mean in the context of pregnancy. This cognitive
,step occurs before taking action, such as notifying the provider
or implementing interventions .
Incorrect Option Rationales:
• A: Documentation is an important nursing responsibility
but represents data recording, not analysis of clinical cues.
• B: Notifying the provider is a subsequent action that
follows after the nurse has analyzed and interpreted the
significance of the findings.
• D: Administering medication represents implementation,
which occurs after analysis, hypothesis generation, and
solution development.
Teaching Point: Clinical judgment requires analyzing cues to
interpret their meaning before selecting nursing actions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Chapter 1: Clinical
Judgment and the Nursing Process.
QUESTION 2
Reference: Clinical Judgment and the Nursing Process —
Prioritization and the Nursing Process
Clinical Scenario:
A postpartum nurse is caring for four clients on a mother-baby
, unit. Client A is 2 hours post-cesarean birth with a heart rate of
110 bpm and blood pressure of 90/50 mm Hg. Client B is 24
hours post-vaginal birth requesting pain medication for perineal
discomfort. Client C is 12 hours post-vaginal birth who has not
voided in 6 hours. Client D is 48 hours post-cesarean birth
reporting breast engorgement. Which client should the nurse
assess first?
Options:
A. Client A with tachycardia and hypotension
B. Client B requesting pain medication
C. Client C with urinary retention
D. Client D reporting breast engorgement
Correct Answer: A. Client A with tachycardia and hypotension
Rationale:
Correct Answer Rationale: Prioritization requires identifying the
client with the most acute, life-threatening condition. Client A's
tachycardia (110 bpm) and hypotension (90/50 mm Hg) may
indicate postpartum hemorrhage or shock, representing a
physiologic emergency requiring immediate assessment .
Airway, breathing, and circulation concerns take priority over
discomfort, urinary retention, or breast engorgement .
Incorrect Option Rationales:
NEWBORN AND WOMEN'S HEALTH
NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
Chapter 1: Clinical Judgment and the Nursing
Process
QUESTION 1
Reference: Clinical Judgment and the Nursing Process —
Components of the Nursing Process
,Clinical Scenario:
A primigravida at 38 weeks gestation is admitted to the labor
and delivery unit in early labor. During the admission
assessment, the nurse notes that the client's blood pressure is
148/92 mm Hg and urine dipstick reveals 2+ protein. The client
reports a headache rated 5 on a 0–10 scale. Which nursing
action demonstrates application of the "Analysis of Cues" step
of the clinical judgment process?
Options:
A. Document the assessment findings in the electronic health
record.
B. Notify the healthcare provider of the elevated blood pressure
and proteinuria.
C. Recognize that these findings may indicate preeclampsia.
D. Administer prescribed antihypertensive medication.
Correct Answer: C. Recognize that these findings may indicate
preeclampsia.
Rationale:
Correct Answer Rationale: Analysis of cues involves
interpreting and clustering assessment findings to identify
patterns and determine their clinical meaning . Recognizing that
elevated blood pressure, proteinuria, and headache may
indicate preeclampsia represents the nurse's analysis of what
these findings mean in the context of pregnancy. This cognitive
,step occurs before taking action, such as notifying the provider
or implementing interventions .
Incorrect Option Rationales:
• A: Documentation is an important nursing responsibility
but represents data recording, not analysis of clinical cues.
• B: Notifying the provider is a subsequent action that
follows after the nurse has analyzed and interpreted the
significance of the findings.
• D: Administering medication represents implementation,
which occurs after analysis, hypothesis generation, and
solution development.
Teaching Point: Clinical judgment requires analyzing cues to
interpret their meaning before selecting nursing actions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Chapter 1: Clinical
Judgment and the Nursing Process.
QUESTION 2
Reference: Clinical Judgment and the Nursing Process —
Prioritization and the Nursing Process
Clinical Scenario:
A postpartum nurse is caring for four clients on a mother-baby
, unit. Client A is 2 hours post-cesarean birth with a heart rate of
110 bpm and blood pressure of 90/50 mm Hg. Client B is 24
hours post-vaginal birth requesting pain medication for perineal
discomfort. Client C is 12 hours post-vaginal birth who has not
voided in 6 hours. Client D is 48 hours post-cesarean birth
reporting breast engorgement. Which client should the nurse
assess first?
Options:
A. Client A with tachycardia and hypotension
B. Client B requesting pain medication
C. Client C with urinary retention
D. Client D reporting breast engorgement
Correct Answer: A. Client A with tachycardia and hypotension
Rationale:
Correct Answer Rationale: Prioritization requires identifying the
client with the most acute, life-threatening condition. Client A's
tachycardia (110 bpm) and hypotension (90/50 mm Hg) may
indicate postpartum hemorrhage or shock, representing a
physiologic emergency requiring immediate assessment .
Airway, breathing, and circulation concerns take priority over
discomfort, urinary retention, or breast engorgement .
Incorrect Option Rationales:
