DAVIS ADVANTAGE FOR MATERNAL-
CHILD NURSING CARE
3RD EDITION
• AUTHOR(S)MEREDITH SCANNELL
TEST BANK
1
Reference
Ch. 1 — Standards of Practice
Stem
A 28-year-old primigravida at 36 weeks’ gestation presents for a
routine prenatal visit reporting mild swelling in her hands and
increased headaches over the past week. Her blood pressure is
pg. 1
,150/95 mm Hg, and urine dipstick shows 2+ protein. The nurse
must prioritize the next action.
A. Advise home rest and repeat blood pressure at next prenatal
visit.
B. Instruct the patient to reduce dietary sodium and return in
48 hours.
C. Arrange same-day evaluation for preeclampsia (repeat BP,
labs, fetal assessment).
D. Teach signs of severe preeclampsia and schedule a follow-up
in one week.
Correct Answer
C
Rationales
Correct (C): Elevated BP with proteinuria at 36 weeks suggests
possible preeclampsia; same-day evaluation (repeat BP, lab
tests for HELLP, fetal testing such as NST/BPP) is necessary to
assess maternal-fetal risk and determine timing of delivery.
Prompt assessment reduces risk of progression to severe
features. This is consistent with standards requiring immediate
pg. 2
,evaluation for hypertensive disorders in pregnancy.
A: Waiting until the next routine visit is unsafe; the BP and
proteinuria are concerning and warrant urgent evaluation.
B: Dietary sodium restriction without clinical evaluation
underestimates risk; preeclampsia requires medical
assessment.
D: Teaching signs is appropriate but scheduling a one-week
follow-up alone delays immediate necessary evaluation.
Teaching Point
New hypertension with proteinuria ≥20 weeks needs immediate
evaluation for preeclampsia.
Citation
Scannell, M. (2025). Davis Advantage for Maternal-Child Nursing
Care (3rd ed.). Ch. 1 — Standards of Practice.
2
Reference
Ch. 1 — Nursing Process
pg. 3
, Stem
During triage in a pediatric clinic, a 3-year-old with fever 39.2°C
(102.6°F), decreased oral intake, dry mucous membranes, and
capillary refill 4 seconds is seen. The RN must determine the
priority nursing diagnosis before planning care.
A. Risk for delayed growth and development related to illness.
B. Deficient fluid volume related to decreased intake and fever.
C. Risk for infection related to fever and decreased intake.
D. Impaired oral mucous membrane related to dry mucous
membranes.
Correct Answer
B
Rationales
Correct (B): Dry mucous membranes, prolonged capillary refill,
decreased intake, and high fever indicate volume depletion;
deficient fluid volume is the priority diagnosis because it is
immediately life-threatening and guides urgent interventions
(fluid rehydration). Prioritization follows the nursing process—
address ABCs and fluid status first.
pg. 4
CHILD NURSING CARE
3RD EDITION
• AUTHOR(S)MEREDITH SCANNELL
TEST BANK
1
Reference
Ch. 1 — Standards of Practice
Stem
A 28-year-old primigravida at 36 weeks’ gestation presents for a
routine prenatal visit reporting mild swelling in her hands and
increased headaches over the past week. Her blood pressure is
pg. 1
,150/95 mm Hg, and urine dipstick shows 2+ protein. The nurse
must prioritize the next action.
A. Advise home rest and repeat blood pressure at next prenatal
visit.
B. Instruct the patient to reduce dietary sodium and return in
48 hours.
C. Arrange same-day evaluation for preeclampsia (repeat BP,
labs, fetal assessment).
D. Teach signs of severe preeclampsia and schedule a follow-up
in one week.
Correct Answer
C
Rationales
Correct (C): Elevated BP with proteinuria at 36 weeks suggests
possible preeclampsia; same-day evaluation (repeat BP, lab
tests for HELLP, fetal testing such as NST/BPP) is necessary to
assess maternal-fetal risk and determine timing of delivery.
Prompt assessment reduces risk of progression to severe
features. This is consistent with standards requiring immediate
pg. 2
,evaluation for hypertensive disorders in pregnancy.
A: Waiting until the next routine visit is unsafe; the BP and
proteinuria are concerning and warrant urgent evaluation.
B: Dietary sodium restriction without clinical evaluation
underestimates risk; preeclampsia requires medical
assessment.
D: Teaching signs is appropriate but scheduling a one-week
follow-up alone delays immediate necessary evaluation.
Teaching Point
New hypertension with proteinuria ≥20 weeks needs immediate
evaluation for preeclampsia.
Citation
Scannell, M. (2025). Davis Advantage for Maternal-Child Nursing
Care (3rd ed.). Ch. 1 — Standards of Practice.
2
Reference
Ch. 1 — Nursing Process
pg. 3
, Stem
During triage in a pediatric clinic, a 3-year-old with fever 39.2°C
(102.6°F), decreased oral intake, dry mucous membranes, and
capillary refill 4 seconds is seen. The RN must determine the
priority nursing diagnosis before planning care.
A. Risk for delayed growth and development related to illness.
B. Deficient fluid volume related to decreased intake and fever.
C. Risk for infection related to fever and decreased intake.
D. Impaired oral mucous membrane related to dry mucous
membranes.
Correct Answer
B
Rationales
Correct (B): Dry mucous membranes, prolonged capillary refill,
decreased intake, and high fever indicate volume depletion;
deficient fluid volume is the priority diagnosis because it is
immediately life-threatening and guides urgent interventions
(fluid rehydration). Prioritization follows the nursing process—
address ABCs and fluid status first.
pg. 4
