INTRODUCTORY MATERNITY &
PEDIATRIC NURSING
5TH EDITION
• AUTHOR(S)NANCY HATFIELD;
CYNTHIA KINCHELOE
TEST BANK
1
Reference: Ch. 1 — The Nurse’s Role in a Changing Maternal–
Child Healthcare Environment
Stem: A 19-year primiparous client is 12 hours postpartum after
an uncomplicated vaginal birth and reports dizziness when
standing. Vital signs: BP 86/52 mm Hg, HR 118 bpm, RR 20 bpm,
temp 37.0°C. She’s breastfeeding in the birthing room; her
mother is present and anxious. Which nursing action is the
priority now?
,A. Assist the client to a sitting position and offer a glass of water.
B. Assess the fundus and amount of lochia at the bedside.
C. Encourage the mother to continue breastfeeding to promote
uterine contraction.
D. Inform the primary provider and prepare for potential IV fluid
bolus.
Correct answer: B
Rationale — Correct (B): Hypotension with tachycardia and
dizziness postpartum raises concern for hypovolemia (possible
bleeding). Assessing the fundus and lochia is the immediate
nursing assessment to identify uterine atony or hemorrhage
before initiating other actions. This aligns with the nursing
process: assess → prioritize interventions for maternal safety.
Rationale — Incorrect (A): Sitting and oral fluids may be helpful
but are not the priority when there’s potential postpartum
hemorrhage; they delay identification of bleeding source.
Rationale — Incorrect (C): Breastfeeding stimulates oxytocin
and uterine contraction, but it is not the immediate first action
when hypotension and tachycardia are present without
confirming uterine status.
Rationale — Incorrect (D): Notifying the provider and preparing
IV fluids may be necessary, but assessment (fundus/lochia)
must occur first to guide appropriate interventions.
Teaching point: Always assess uterine tone and lochia first with
postpartum hemodynamic changes.
,Citation: Hatfield, N., & Kincheloe, C. (2023). Introductory
maternity & pediatric nursing (5th ed.). Ch. 1.
2
Reference: Ch. 1 — The Nurse’s Role in a Changing Maternal–
Child Healthcare Environment
Stem: A 4-year-old child arrives at the pediatric clinic with fever
(38.5°C), ear pain, and irritability. The parent voices limited
English proficiency and brings a teenage sibling as the
interpreter. Which action by the nurse best reflects family-
centered, safe practice?
A. Ask the teenage sibling to interpret because they know the
family best.
B. Use a professional medical interpreter (in person or phone)
to obtain history and teach.
C. Rely on nonverbal cues and proceed with assessment
without formal interpretation.
D. Delay history and start treatment based on the parent’s brief
statements.
Correct answer: B
Rationale — Correct (B): Using a professional medical
interpreter ensures accurate communication, preserves
confidentiality, and supports family-centered care. It reduces
errors in history, consent, and teaching—key safety priorities in
maternal-child nursing.
, Rationale — Incorrect (A): Using a minor as interpreter is
inappropriate ethically and legally and risks miscommunication.
Rationale — Incorrect (C): Nonverbal cues are insufficient for
clinical history and informed decisions.
Rationale — Incorrect (D): Delaying full history or proceeding
without proper interpretation risks inappropriate treatment and
violates family-centered communication standards.
Teaching point: Use professional interpreters to ensure
accurate, confidential communication.
Citation: Hatfield, N., & Kincheloe, C. (2023). Introductory
maternity & pediatric nursing (5th ed.). Ch. 1.
3
Reference: Ch. 1 — The Nurse’s Role in a Changing Maternal–
Child Healthcare Environment
Stem: On a busy med-surg unit, a nurse caring for a postpartum
client with preeclampsia is asked to delegate obtaining a
urinalysis for protein to an experienced nursing assistant (NA).
The NA expresses uncertainty about the procedure. Which
action should the nurse take?
A. Delegate the task to the NA and provide written instructions
only.
B. Perform the urinalysis personally because it’s part of the
nurse’s assessment.
C. Delegate to the NA after a brief demonstration and
PEDIATRIC NURSING
5TH EDITION
• AUTHOR(S)NANCY HATFIELD;
CYNTHIA KINCHELOE
TEST BANK
1
Reference: Ch. 1 — The Nurse’s Role in a Changing Maternal–
Child Healthcare Environment
Stem: A 19-year primiparous client is 12 hours postpartum after
an uncomplicated vaginal birth and reports dizziness when
standing. Vital signs: BP 86/52 mm Hg, HR 118 bpm, RR 20 bpm,
temp 37.0°C. She’s breastfeeding in the birthing room; her
mother is present and anxious. Which nursing action is the
priority now?
,A. Assist the client to a sitting position and offer a glass of water.
B. Assess the fundus and amount of lochia at the bedside.
C. Encourage the mother to continue breastfeeding to promote
uterine contraction.
D. Inform the primary provider and prepare for potential IV fluid
bolus.
Correct answer: B
Rationale — Correct (B): Hypotension with tachycardia and
dizziness postpartum raises concern for hypovolemia (possible
bleeding). Assessing the fundus and lochia is the immediate
nursing assessment to identify uterine atony or hemorrhage
before initiating other actions. This aligns with the nursing
process: assess → prioritize interventions for maternal safety.
Rationale — Incorrect (A): Sitting and oral fluids may be helpful
but are not the priority when there’s potential postpartum
hemorrhage; they delay identification of bleeding source.
Rationale — Incorrect (C): Breastfeeding stimulates oxytocin
and uterine contraction, but it is not the immediate first action
when hypotension and tachycardia are present without
confirming uterine status.
Rationale — Incorrect (D): Notifying the provider and preparing
IV fluids may be necessary, but assessment (fundus/lochia)
must occur first to guide appropriate interventions.
Teaching point: Always assess uterine tone and lochia first with
postpartum hemodynamic changes.
,Citation: Hatfield, N., & Kincheloe, C. (2023). Introductory
maternity & pediatric nursing (5th ed.). Ch. 1.
2
Reference: Ch. 1 — The Nurse’s Role in a Changing Maternal–
Child Healthcare Environment
Stem: A 4-year-old child arrives at the pediatric clinic with fever
(38.5°C), ear pain, and irritability. The parent voices limited
English proficiency and brings a teenage sibling as the
interpreter. Which action by the nurse best reflects family-
centered, safe practice?
A. Ask the teenage sibling to interpret because they know the
family best.
B. Use a professional medical interpreter (in person or phone)
to obtain history and teach.
C. Rely on nonverbal cues and proceed with assessment
without formal interpretation.
D. Delay history and start treatment based on the parent’s brief
statements.
Correct answer: B
Rationale — Correct (B): Using a professional medical
interpreter ensures accurate communication, preserves
confidentiality, and supports family-centered care. It reduces
errors in history, consent, and teaching—key safety priorities in
maternal-child nursing.
, Rationale — Incorrect (A): Using a minor as interpreter is
inappropriate ethically and legally and risks miscommunication.
Rationale — Incorrect (C): Nonverbal cues are insufficient for
clinical history and informed decisions.
Rationale — Incorrect (D): Delaying full history or proceeding
without proper interpretation risks inappropriate treatment and
violates family-centered communication standards.
Teaching point: Use professional interpreters to ensure
accurate, confidential communication.
Citation: Hatfield, N., & Kincheloe, C. (2023). Introductory
maternity & pediatric nursing (5th ed.). Ch. 1.
3
Reference: Ch. 1 — The Nurse’s Role in a Changing Maternal–
Child Healthcare Environment
Stem: On a busy med-surg unit, a nurse caring for a postpartum
client with preeclampsia is asked to delegate obtaining a
urinalysis for protein to an experienced nursing assistant (NA).
The NA expresses uncertainty about the procedure. Which
action should the nurse take?
A. Delegate the task to the NA and provide written instructions
only.
B. Perform the urinalysis personally because it’s part of the
nurse’s assessment.
C. Delegate to the NA after a brief demonstration and
