FOUNDATIONS OF MATERNAL-
NEWBORN AND WOMEN'S HEALTH
NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
Foundations of Maternal-Newborn and Women's
Health Nursing, 8th Edition
Chapter 1: Clinical Judgment and the Nursing
Process
,Question 1
Reference: Clinical Judgment and the Nursing Process —
Application of the Nursing Process, Assessment Phase
A nurse is admitting a 32-year-old primigravida at 38 weeks'
gestation to the labor and delivery unit. The client reports
contractions every 5 minutes for the past 2 hours. Which action
should the nurse perform first during the assessment phase of
the nursing process?
A. Develop a plan of care based on the client's stated concerns
B. Collect subjective and objective data about the client's
condition
C. Implement interventions to reduce the client's discomfort
D. Determine whether the client's goals for labor have been
met
Correct Answer: B. Collect subjective and objective data about
the client's condition
Rationale for Correct Answer: The assessment phase of the
nursing process is the first step and involves collecting
comprehensive subjective and objective data about the client's
health status. During admission to labor and delivery, the nurse
must first gather information about the client's contractions,
,cervical status, fetal heart rate, and other relevant findings
before proceeding to planning or intervention .
Rationale for Incorrect Answers:
• A: Developing a plan of care occurs during the planning
phase, which follows assessment and cannot be completed
without initial data collection.
• C: Implementing interventions occurs during the
implementation phase and should not precede
assessment.
• D: Determining whether goals have been met is part of the
evaluation phase, the final step of the nursing process.
Teaching Point: Assessment is the foundation of the nursing
process; data collection must precede all other nursing actions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process.
Question 2
Reference: Clinical Judgment and the Nursing Process —
Nursing Process: Diagnosis
A postpartum client who gave birth vaginally 12 hours ago
reports severe perineal pain and difficulty voiding. On
, assessment, the nurse notes a firm, displaced uterus and a full
bladder. The nurse identifies the nursing diagnosis of "Impaired
Urinary Elimination related to perineal trauma and edema."
Based on this diagnosis, which finding would the nurse expect
to observe?
A. The client's urine output is 200 mL over the past 4 hours
B. The client states she feels the urge to void every 2 hours
C. The client's bladder is palpable above the symphysis pubis
D. The client reports burning with urination
Correct Answer: C. The client's bladder is palpable above the
symphysis pubis
Rationale for Correct Answer: A full bladder that is palpable
above the symphysis pubis is a classic objective finding
associated with impaired urinary elimination. The firm,
displaced uterus noted by the nurse is also consistent with
bladder distention, which displaces the uterus upward and to
the side .
Rationale for Incorrect Answers:
• A: A urine output of 200 mL over 4 hours (50 mL/hour) is
within normal range and does not support the diagnosis of
impaired elimination.
• B: Feeling the urge to void every 2 hours represents a
normal urinary pattern, not impaired elimination.
NEWBORN AND WOMEN'S HEALTH
NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
Foundations of Maternal-Newborn and Women's
Health Nursing, 8th Edition
Chapter 1: Clinical Judgment and the Nursing
Process
,Question 1
Reference: Clinical Judgment and the Nursing Process —
Application of the Nursing Process, Assessment Phase
A nurse is admitting a 32-year-old primigravida at 38 weeks'
gestation to the labor and delivery unit. The client reports
contractions every 5 minutes for the past 2 hours. Which action
should the nurse perform first during the assessment phase of
the nursing process?
A. Develop a plan of care based on the client's stated concerns
B. Collect subjective and objective data about the client's
condition
C. Implement interventions to reduce the client's discomfort
D. Determine whether the client's goals for labor have been
met
Correct Answer: B. Collect subjective and objective data about
the client's condition
Rationale for Correct Answer: The assessment phase of the
nursing process is the first step and involves collecting
comprehensive subjective and objective data about the client's
health status. During admission to labor and delivery, the nurse
must first gather information about the client's contractions,
,cervical status, fetal heart rate, and other relevant findings
before proceeding to planning or intervention .
Rationale for Incorrect Answers:
• A: Developing a plan of care occurs during the planning
phase, which follows assessment and cannot be completed
without initial data collection.
• C: Implementing interventions occurs during the
implementation phase and should not precede
assessment.
• D: Determining whether goals have been met is part of the
evaluation phase, the final step of the nursing process.
Teaching Point: Assessment is the foundation of the nursing
process; data collection must precede all other nursing actions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process.
Question 2
Reference: Clinical Judgment and the Nursing Process —
Nursing Process: Diagnosis
A postpartum client who gave birth vaginally 12 hours ago
reports severe perineal pain and difficulty voiding. On
, assessment, the nurse notes a firm, displaced uterus and a full
bladder. The nurse identifies the nursing diagnosis of "Impaired
Urinary Elimination related to perineal trauma and edema."
Based on this diagnosis, which finding would the nurse expect
to observe?
A. The client's urine output is 200 mL over the past 4 hours
B. The client states she feels the urge to void every 2 hours
C. The client's bladder is palpable above the symphysis pubis
D. The client reports burning with urination
Correct Answer: C. The client's bladder is palpable above the
symphysis pubis
Rationale for Correct Answer: A full bladder that is palpable
above the symphysis pubis is a classic objective finding
associated with impaired urinary elimination. The firm,
displaced uterus noted by the nurse is also consistent with
bladder distention, which displaces the uterus upward and to
the side .
Rationale for Incorrect Answers:
• A: A urine output of 200 mL over 4 hours (50 mL/hour) is
within normal range and does not support the diagnosis of
impaired elimination.
• B: Feeling the urge to void every 2 hours represents a
normal urinary pattern, not impaired elimination.
