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 —
Standards of Practice for Perinatal and Women's Health Nursing
,Clinical Scenario: A nurse is providing care for a woman in the
immediate postpartum period following an uncomplicated
vaginal birth. The nurse notes the patient's fundus is firm,
midline, and at the level of the umbilicus, with moderate lochia
rubra. The patient states, "I'm feeling dizzy and lightheaded
when I try to sit up." Using the nursing process, which action
should the nurse take first?
Options:
A. Document the findings as expected postpartum adaptations.
B. Assess the patient's blood pressure and heart rate.
C. Encourage the patient to ambulate to the bathroom.
D. Instruct the patient to take slow, deep breaths.
Correct Answer: B. Assess the patient's blood pressure and
heart rate.
Rationale:
Correct Answer: The nursing process requires assessment as
the first step before implementing interventions. Dizziness and
lightheadedness may indicate orthostatic hypotension or
hemorrhage, requiring immediate blood pressure and heart
rate evaluation. Assessment must precede intervention to
ensure safe, individualized care.
Incorrect Options:
, • A: Documenting expected findings is premature when the
patient is reporting a new symptom that may indicate a
complication requiring further assessment.
• C: Encouraging ambulation without first assessing the
cause of dizziness could place the patient at risk for falls or
injury.
• D: Instructing deep breathing does not address the
potential underlying cause of the dizziness and delays
necessary assessment.
Teaching Point: Assessment precedes intervention—evaluate
abnormal symptoms before implementing actions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process — Standards of Practice.
Question 2
Reference: Clinical Judgment and the Nursing Process — Safety
and Quality Within Women's Health
Clinical Scenario: A newly graduated nurse is caring for a
laboring patient receiving oxytocin. The patient's contractions
are occurring every 2 minutes, lasting 90 seconds, with a resting
uterine tone of 30 mmHg. The fetal heart rate shows late
decelerations. The new nurse is unsure how to interpret these
, findings and does not know what to do. According to principles
of safety and quality in women's health nursing, what is the
priority action?
Options:
A. Review the facility's policy and procedure manual.
B. Ask another newly graduated nurse for advice.
C. Notify the charge nurse or more experienced nurse
immediately.
D. Decrease the oxytocin infusion rate without consulting
anyone.
Correct Answer: C. Notify the charge nurse or more
experienced nurse immediately.
Rationale:
Correct Answer: Safety and quality in perinatal nursing require
nurses to recognize when a situation exceeds their knowledge
or experience and seek assistance from more experienced
colleagues. This situation involves abnormal uterine activity and
fetal compromise requiring prompt intervention. Consulting a
more experienced nurse ensures timely, appropriate action.
Incorrect Options:
• A: Reviewing the policy manual delays critical action when
fetal compromise is occurring and the situation requires
immediate intervention.
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 —
Standards of Practice for Perinatal and Women's Health Nursing
,Clinical Scenario: A nurse is providing care for a woman in the
immediate postpartum period following an uncomplicated
vaginal birth. The nurse notes the patient's fundus is firm,
midline, and at the level of the umbilicus, with moderate lochia
rubra. The patient states, "I'm feeling dizzy and lightheaded
when I try to sit up." Using the nursing process, which action
should the nurse take first?
Options:
A. Document the findings as expected postpartum adaptations.
B. Assess the patient's blood pressure and heart rate.
C. Encourage the patient to ambulate to the bathroom.
D. Instruct the patient to take slow, deep breaths.
Correct Answer: B. Assess the patient's blood pressure and
heart rate.
Rationale:
Correct Answer: The nursing process requires assessment as
the first step before implementing interventions. Dizziness and
lightheadedness may indicate orthostatic hypotension or
hemorrhage, requiring immediate blood pressure and heart
rate evaluation. Assessment must precede intervention to
ensure safe, individualized care.
Incorrect Options:
, • A: Documenting expected findings is premature when the
patient is reporting a new symptom that may indicate a
complication requiring further assessment.
• C: Encouraging ambulation without first assessing the
cause of dizziness could place the patient at risk for falls or
injury.
• D: Instructing deep breathing does not address the
potential underlying cause of the dizziness and delays
necessary assessment.
Teaching Point: Assessment precedes intervention—evaluate
abnormal symptoms before implementing actions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process — Standards of Practice.
Question 2
Reference: Clinical Judgment and the Nursing Process — Safety
and Quality Within Women's Health
Clinical Scenario: A newly graduated nurse is caring for a
laboring patient receiving oxytocin. The patient's contractions
are occurring every 2 minutes, lasting 90 seconds, with a resting
uterine tone of 30 mmHg. The fetal heart rate shows late
decelerations. The new nurse is unsure how to interpret these
, findings and does not know what to do. According to principles
of safety and quality in women's health nursing, what is the
priority action?
Options:
A. Review the facility's policy and procedure manual.
B. Ask another newly graduated nurse for advice.
C. Notify the charge nurse or more experienced nurse
immediately.
D. Decrease the oxytocin infusion rate without consulting
anyone.
Correct Answer: C. Notify the charge nurse or more
experienced nurse immediately.
Rationale:
Correct Answer: Safety and quality in perinatal nursing require
nurses to recognize when a situation exceeds their knowledge
or experience and seek assistance from more experienced
colleagues. This situation involves abnormal uterine activity and
fetal compromise requiring prompt intervention. Consulting a
more experienced nurse ensures timely, appropriate action.
Incorrect Options:
• A: Reviewing the policy manual delays critical action when
fetal compromise is occurring and the situation requires
immediate intervention.
