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
1. Reference
Reference: Clinical Judgment and the Nursing Process —
Foundations of Maternal-Newborn Nursing
2. Clinical Scenario
,A registered nurse in an antepartum clinic is performing an
initial assessment on a client who is at 10 weeks of gestation.
The nurse collects baseline vital signs, obtains a health history,
and listens to the client's concerns about her pregnancy.
According to the NCSBN Clinical Judgment Measurement Model
(CJMM) and the nursing process, which action by the nurse
demonstrates the "Recognizing Cues" step?
3. Options
A. Documenting that the client's blood pressure reading of
118/76 mmHg is within the expected range for early pregnancy.
B. Identifying that a reported weight loss of 5 pounds during the
first trimester requires further exploration. C. Determining that
the client is at risk for fluid volume deficit related to persistent
morning sickness. D. Formulating a teaching plan regarding
dietary modifications to manage first-trimester nausea.
4. Correct Answer
Correct Answer: B. Identifying that a reported weight loss of 5
pounds during the first trimester requires further exploration.
5. Rationales
• Correct Answer (B): Recognizing cues involves identifying
relevant, significant, or unexpected assessment data from
subjective and objective findings. Recognizing that a 5-
pound weight loss in the first trimester is a cue that
, requires additional investigation represents the initial step
of clinical judgment within the nursing process.
• Incorrect Option (A): Documenting that a vital sign is
within expected limits describes analyzing or validating
data, rather than recognizing a significant clinical cue that
requires further judgment.
• Incorrect Option (C): Determining a potential risk or
problem represents the "Analyzing Cues" or "Prioritizing
Hypotheses" phase of the clinical judgment model, which
occurs after initial cue recognition.
• Incorrect Option (D): Formulating a teaching plan is part of
the "Generating Solutions" or "Planning" phase of the
nursing process, which follows the identification and
analysis of clinical cues.
6. Teaching Point
Teaching Point: Recognizing cues requires the nurse to identify
clinically relevant findings and unexpected subjective or
objective data.
7. Citation
Murray, S. (2024). Foundations of Maternal-Newborn and
Women's Health Nursing (8th ed.). Clinical Judgment and the
Nursing Process.
1. Reference
, Reference: Safety and Quality Within Women’s Health —
National Patient Safety Initiatives
2. Clinical Scenario
A labor and delivery unit has implemented standard safety
bundles to reduce maternal morbidity and mortality. During a
handover report, the nurse notes that a laboring client has
multiple risk factors for postpartum hemorrhage. To align with
established maternal safety guidelines, which action should the
nurse take first?
3. Options
A. Administer prophylactic oxytocin intravenously before the
delivery of the placenta. B. Quantify blood loss visually
immediately following the third stage of labor. C. Perform a
baseline risk assessment and ensure hemorrhage supplies are
readily accessible. D. Notify the blood bank to crossmatch four
units of packed red blood cells immediately.
4. Correct Answer
Correct Answer: C. Perform a baseline risk assessment and
ensure hemorrhage supplies are readily accessible.
5. Rationales
• Correct Answer (C): Maternal safety bundles emphasize
readiness and recognition. Performing a baseline risk
assessment upon admission and verifying that hemorrhage
NEWBORN AND WOMEN'S HEALTH
NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
Chapter 1: Clinical Judgment and the Nursing
Process
1. Reference
Reference: Clinical Judgment and the Nursing Process —
Foundations of Maternal-Newborn Nursing
2. Clinical Scenario
,A registered nurse in an antepartum clinic is performing an
initial assessment on a client who is at 10 weeks of gestation.
The nurse collects baseline vital signs, obtains a health history,
and listens to the client's concerns about her pregnancy.
According to the NCSBN Clinical Judgment Measurement Model
(CJMM) and the nursing process, which action by the nurse
demonstrates the "Recognizing Cues" step?
3. Options
A. Documenting that the client's blood pressure reading of
118/76 mmHg is within the expected range for early pregnancy.
B. Identifying that a reported weight loss of 5 pounds during the
first trimester requires further exploration. C. Determining that
the client is at risk for fluid volume deficit related to persistent
morning sickness. D. Formulating a teaching plan regarding
dietary modifications to manage first-trimester nausea.
4. Correct Answer
Correct Answer: B. Identifying that a reported weight loss of 5
pounds during the first trimester requires further exploration.
5. Rationales
• Correct Answer (B): Recognizing cues involves identifying
relevant, significant, or unexpected assessment data from
subjective and objective findings. Recognizing that a 5-
pound weight loss in the first trimester is a cue that
, requires additional investigation represents the initial step
of clinical judgment within the nursing process.
• Incorrect Option (A): Documenting that a vital sign is
within expected limits describes analyzing or validating
data, rather than recognizing a significant clinical cue that
requires further judgment.
• Incorrect Option (C): Determining a potential risk or
problem represents the "Analyzing Cues" or "Prioritizing
Hypotheses" phase of the clinical judgment model, which
occurs after initial cue recognition.
• Incorrect Option (D): Formulating a teaching plan is part of
the "Generating Solutions" or "Planning" phase of the
nursing process, which follows the identification and
analysis of clinical cues.
6. Teaching Point
Teaching Point: Recognizing cues requires the nurse to identify
clinically relevant findings and unexpected subjective or
objective data.
7. Citation
Murray, S. (2024). Foundations of Maternal-Newborn and
Women's Health Nursing (8th ed.). Clinical Judgment and the
Nursing Process.
1. Reference
, Reference: Safety and Quality Within Women’s Health —
National Patient Safety Initiatives
2. Clinical Scenario
A labor and delivery unit has implemented standard safety
bundles to reduce maternal morbidity and mortality. During a
handover report, the nurse notes that a laboring client has
multiple risk factors for postpartum hemorrhage. To align with
established maternal safety guidelines, which action should the
nurse take first?
3. Options
A. Administer prophylactic oxytocin intravenously before the
delivery of the placenta. B. Quantify blood loss visually
immediately following the third stage of labor. C. Perform a
baseline risk assessment and ensure hemorrhage supplies are
readily accessible. D. Notify the blood bank to crossmatch four
units of packed red blood cells immediately.
4. Correct Answer
Correct Answer: C. Perform a baseline risk assessment and
ensure hemorrhage supplies are readily accessible.
5. Rationales
• Correct Answer (C): Maternal safety bundles emphasize
readiness and recognition. Performing a baseline risk
assessment upon admission and verifying that hemorrhage
