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: Foundations for Nursing Care of Childbearing
Families — Clinical Judgment and the Nursing Process
Clinical Scenario:
,A nurse is caring for a 28-year-old primigravida at 34 weeks of
gestation who presents to the prenatal clinic reporting
persistent frontal headaches and visual changes. The nurse
obtains vital signs, noting a blood pressure of 158/96 mmHg,
and performs a dipstick urinalysis showing 2+ protein. Which
action by the nurse represents the "Analyze Cues / Formulate
Nursing Diagnosis" step of the nursing process and Clinical
Judgment Measurement Model?
• A. Assessing the patient's deep tendon reflexes and
checking for clonus
• B. Determining that the patient is experiencing signs of
preeclampsia requiring urgent intervention
• C. Administering an prescribed antihypertensive
medication to reduce blood pressure
• D. Reassessing the patient's blood pressure and urinary
protein levels after 30 minutes
Correct Answer: B. Determining that the patient is experiencing
signs of preeclampsia requiring urgent intervention
Rationales:
• Correct Answer: Identifying that the cluster of cues (
elevated blood pressure, protein in the urine, headache,
and visual disturbance) points to a specific maternal
complication (preeclampsia) represents analyzing cues and
, formulating a clinical hypothesis/diagnosis. This cognitive
step bridges initial data collection with generating
solutions and taking nursing action.
• Incorrect Options:
o A: Assessing deep tendon reflexes and clonus is part
of the data collection (Recognize Cues / Assessment)
phase, not the analysis phase.
o C: Administering medication is an implementation
step (Take Action), which occurs after cues have been
recognized and analyzed.
o D: Reassessing blood pressure and urinary protein is
part of the evaluation phase to determine the
patient's response or status change over time.
Teaching Point: Analyzing cues involves synthesizing
assessment data to identify patient problems and clinical
priorities.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process.
Question 2
Reference: Foundations for Nursing Care of Childbearing
Families — Safety And Quality Within Women’s Health
, Clinical Scenario:
A maternal-newborn unit clinical nurse specialist is reviewing
safety events and quality metrics. The unit has implemented
standardized safety bundles and check-lists for obstetric
hemorrhage and severe hypertension. The nurse recognizes
that the primary goal of integrating these quality and safety
initiatives into routine perinatal nursing practice is to:
• A. Eliminate the need for individual clinical judgment
during maternal emergencies
• B. Standardize care to reduce preventable maternal
mortality and morbidity
• C. Shift clinical decision-making responsibilities from
nurses to attending physicians
• D. Provide legal protection for the hospital against patient
malpractice claims
Correct Answer: B. Standardize care to reduce preventable
maternal mortality and morbidity
Rationales:
• Correct Answer: National safety initiatives, such as safety
bundles and standardized protocols in maternal health, are
designed to eliminate variation in care, facilitate early
recognition of critical cues, and improve outcomes,
thereby preventing avoidable maternal illness and death.
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: Foundations for Nursing Care of Childbearing
Families — Clinical Judgment and the Nursing Process
Clinical Scenario:
,A nurse is caring for a 28-year-old primigravida at 34 weeks of
gestation who presents to the prenatal clinic reporting
persistent frontal headaches and visual changes. The nurse
obtains vital signs, noting a blood pressure of 158/96 mmHg,
and performs a dipstick urinalysis showing 2+ protein. Which
action by the nurse represents the "Analyze Cues / Formulate
Nursing Diagnosis" step of the nursing process and Clinical
Judgment Measurement Model?
• A. Assessing the patient's deep tendon reflexes and
checking for clonus
• B. Determining that the patient is experiencing signs of
preeclampsia requiring urgent intervention
• C. Administering an prescribed antihypertensive
medication to reduce blood pressure
• D. Reassessing the patient's blood pressure and urinary
protein levels after 30 minutes
Correct Answer: B. Determining that the patient is experiencing
signs of preeclampsia requiring urgent intervention
Rationales:
• Correct Answer: Identifying that the cluster of cues (
elevated blood pressure, protein in the urine, headache,
and visual disturbance) points to a specific maternal
complication (preeclampsia) represents analyzing cues and
, formulating a clinical hypothesis/diagnosis. This cognitive
step bridges initial data collection with generating
solutions and taking nursing action.
• Incorrect Options:
o A: Assessing deep tendon reflexes and clonus is part
of the data collection (Recognize Cues / Assessment)
phase, not the analysis phase.
o C: Administering medication is an implementation
step (Take Action), which occurs after cues have been
recognized and analyzed.
o D: Reassessing blood pressure and urinary protein is
part of the evaluation phase to determine the
patient's response or status change over time.
Teaching Point: Analyzing cues involves synthesizing
assessment data to identify patient problems and clinical
priorities.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process.
Question 2
Reference: Foundations for Nursing Care of Childbearing
Families — Safety And Quality Within Women’s Health
, Clinical Scenario:
A maternal-newborn unit clinical nurse specialist is reviewing
safety events and quality metrics. The unit has implemented
standardized safety bundles and check-lists for obstetric
hemorrhage and severe hypertension. The nurse recognizes
that the primary goal of integrating these quality and safety
initiatives into routine perinatal nursing practice is to:
• A. Eliminate the need for individual clinical judgment
during maternal emergencies
• B. Standardize care to reduce preventable maternal
mortality and morbidity
• C. Shift clinical decision-making responsibilities from
nurses to attending physicians
• D. Provide legal protection for the hospital against patient
malpractice claims
Correct Answer: B. Standardize care to reduce preventable
maternal mortality and morbidity
Rationales:
• Correct Answer: National safety initiatives, such as safety
bundles and standardized protocols in maternal health, are
designed to eliminate variation in care, facilitate early
recognition of critical cues, and improve outcomes,
thereby preventing avoidable maternal illness and death.
