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 28-year-old primiparous woman calls the clinic reporting mild
uterine cramping 2 days postpartum and asks whether she
should come in for an assessment. She is breastfeeding, stable
vital signs at home, and her partner is supportive but anxious
,because this is their first infant. As the triage nurse, what is the
most appropriate initial nursing action?
A. Advise her to come to the clinic immediately for a full
physical assessment.
B. Conduct a focused telephone assessment using guided
questions about bleeding, fever, and pain.
C. Reassure her that mild cramping is normal postpartum and
advise no further action unless symptoms worsen.
D. Tell her to go to the emergency department because
postpartum problems can escalate quickly.
Correct Answer
B
Rationale — Correct (B)
A focused telephone assessment uses clinical judgment to
determine severity and need for in-person care, addressing
safety (bleeding, fever, pain). It is efficient, family-centered, and
consistent with nursing triage and scope of practice in
outpatient maternal–child care.
Rationales — Incorrect
A. Immediate clinic visit may be unnecessary and burdensome
without assessment; it bypasses triage.
C. Blanket reassurance without assessment risks missing red
flags like hemorrhage or infection.
D. ED referral is excessive for stable, mild symptoms and may
fragment care.
,Teaching Point
Use focused triage questions to prioritize in-person visits and
ensure safety.
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
An LPN working on a pediatric unit is assigned to care for four
children with diverse needs, including one with unstable
respiratory status requiring frequent reassessment. Which
assignment decision best reflects safe delegation and scope of
practice?
A. Assign the LPN to the child with unstable respiratory status
because LPNs can provide frequent assessments.
B. Assign the LPN to stable, chronic needs (medication
administration and routine assessments) and delegate frequent
respiratory assessments to an RN.
C. Tell the LPN to perform independent care planning for all four
children without RN supervision.
, D. Have the LPN manage the unstable child and assign the RN to
document only.
Correct Answer
B
Rationale — Correct (B)
Matching patient acuity to licensure and skill ensures safety.
RNs retain responsibility for unstable patients and complex
assessments; LPNs provide skilled, supportive care for stable
patients, medication administration, and routine tasks under RN
supervision.
Rationales — Incorrect
A. Unsafe: unstable respiratory status requires RN assessment
and titration of care.
C. Unsafe and outside LPN scope: independent comprehensive
care planning for complex cases requires RN licensure.
D. Unsafe: documentation only by RN does not match the
needed direct clinical management.
Teaching Point
Assign by acuity—unstable patients require RN management;
delegate stable tasks to LPNs.
Citation
Hatfield, N., & Kincheloe, C. (2023). Introductory maternity &
pediatric nursing (5th ed.). Ch. 1.
3
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 28-year-old primiparous woman calls the clinic reporting mild
uterine cramping 2 days postpartum and asks whether she
should come in for an assessment. She is breastfeeding, stable
vital signs at home, and her partner is supportive but anxious
,because this is their first infant. As the triage nurse, what is the
most appropriate initial nursing action?
A. Advise her to come to the clinic immediately for a full
physical assessment.
B. Conduct a focused telephone assessment using guided
questions about bleeding, fever, and pain.
C. Reassure her that mild cramping is normal postpartum and
advise no further action unless symptoms worsen.
D. Tell her to go to the emergency department because
postpartum problems can escalate quickly.
Correct Answer
B
Rationale — Correct (B)
A focused telephone assessment uses clinical judgment to
determine severity and need for in-person care, addressing
safety (bleeding, fever, pain). It is efficient, family-centered, and
consistent with nursing triage and scope of practice in
outpatient maternal–child care.
Rationales — Incorrect
A. Immediate clinic visit may be unnecessary and burdensome
without assessment; it bypasses triage.
C. Blanket reassurance without assessment risks missing red
flags like hemorrhage or infection.
D. ED referral is excessive for stable, mild symptoms and may
fragment care.
,Teaching Point
Use focused triage questions to prioritize in-person visits and
ensure safety.
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
An LPN working on a pediatric unit is assigned to care for four
children with diverse needs, including one with unstable
respiratory status requiring frequent reassessment. Which
assignment decision best reflects safe delegation and scope of
practice?
A. Assign the LPN to the child with unstable respiratory status
because LPNs can provide frequent assessments.
B. Assign the LPN to stable, chronic needs (medication
administration and routine assessments) and delegate frequent
respiratory assessments to an RN.
C. Tell the LPN to perform independent care planning for all four
children without RN supervision.
, D. Have the LPN manage the unstable child and assign the RN to
document only.
Correct Answer
B
Rationale — Correct (B)
Matching patient acuity to licensure and skill ensures safety.
RNs retain responsibility for unstable patients and complex
assessments; LPNs provide skilled, supportive care for stable
patients, medication administration, and routine tasks under RN
supervision.
Rationales — Incorrect
A. Unsafe: unstable respiratory status requires RN assessment
and titration of care.
C. Unsafe and outside LPN scope: independent comprehensive
care planning for complex cases requires RN licensure.
D. Unsafe: documentation only by RN does not match the
needed direct clinical management.
Teaching Point
Assign by acuity—unstable patients require RN management;
delegate stable tasks to LPNs.
Citation
Hatfield, N., & Kincheloe, C. (2023). Introductory maternity &
pediatric nursing (5th ed.). Ch. 1.
3
