TEST BANK FOR gg gg
Murray Foundations of Maternal-Newborn and Women's Health Nursing,
gg gg gg gg gg gg gg
8th Edition
gg gg
Chapter 01: gg
MULTIPLE CHOICE gg
1. A nurse educator is teaching a group of nursing students about the history of
gg gg gg gg gg gg gg gg gg gg gg gg gg
family-centered maternity care. Which statement should the nurse include in the teaching
gg gg gg gg gg gg gg gg gg gg gg
session?
gg
a. The Sheppard-Towner Act of 1921 promoted family-centered care.
gg gg gg gg gg gg gg
b. Changes in pharmacologic management of labor prompted family-centered
gg gg gg gg gg gg gg
care. gg
c. Demands by physicians for family involvement in childbirth increased the
gg gg gg gg gg gg gg gg gg
practice gg
of family-centered care.
gg gg
d. Parental requests that infants be allowed to remain with them rather than in a
gg gg gg gg gg gg gg gg gg gg gg gg gg
nursery initiated the practice of family-centered care.
gg gg gg gg gg gg
ANS: g g D
As research began to identify the benefits of early, extended parent–infant contact,
gg gg gg gg gg gg gg gg gg gg gg
parents began to insist that the infant remain with them. This gradually developed
gg gg gg gg gg gg gg gg gg gg gg gg gg
into the practice of rooming-in and finally to family-centered maternity care. The
gg gg gg gg gg gg gg gg gg gg gg gg
Sheppard-Towner Act provided funds for state-managed programs for mothers and
gg gg gg gg gg gg gg gg gg gg
children but did not promote family-centered care. The changes in pharmacologic
gg gg gg gg gg gg gg gg gg gg gg
management of labor were not a factor in family-centered maternity care. Family-
gg gg gg gg gg gg gg gg gg gg gg gg
centered care was a request by parents, not physicians.
gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step: gg gg g g gg gg
Planning MSC: Patient Needs: Health Promotion and Maintenance
gg gg g g gg gg gg gg gg
2. Expectant parents ask a prenatal nurse educator, ―Which setting for childbirth limits
gg gg gg gg gg gg gg gg gg gg gg
the amount of parent–infant interaction?‖ Which answer should the nurse provide
gg gg gg gg gg gg gg gg gg gg gg
for these parents in order to assist them in choosing an appropriate birth setting?
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
a. Birth center gg
b. Home birth gg
c. Traditional hospital birth gg gg
d. Labor, birth, and recovery gg gg gg
room gg
ANS: g g C
In the traditional hospital setting, the mother may see the infant for only short
gg gg gg gg gg gg gg gg gg gg gg gg gg
feeding periods, and the infant is cared for in a separate nursery. Birth centers are
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
set up to allow an increase in parent–infant contact. Home births allow the greatest
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
amount of
gg gg
parent–infant contact. The labor, birth, recovery, and postpartum room setting allows for
gg gg gg gg gg gg gg gg gg gg gg
increased parent–infant contact.
gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: gg gg g g gg gg
Planning MSC: Patient Needs: Health Promotion and Maintenance
gg gg g g gg gg gg gg gg
,3. Which statement best describes the advantage of a labor, birth, recovery, and
gg gg gg gg gg gg gg gg gg gg gg
gg postpartum (LDRP) room? gg gg
a. The family is in a familiar environment.
gg gg gg gg gg gg
b. They are less expensive than traditional hospital rooms.
gg gg gg gg gg gg gg
c. The infant is removed to the nursery to allow the mother to
gg gg gg gg gg gg gg gg gg gg gg
rest.
gg
d. The woman‘s support system is encouraged to stay until
gg gg gg gg gg gg gg gg
discharge.
gg
ANS: g g D
Sleeping equipment is provided in a private room. A hospital setting is never a
gg gg gg gg gg gg gg gg gg gg gg gg gg
familiar environment to new parents. An LDRP room is not less expensive than a
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
traditional hospital room. The baby remains with the mother at all times and is not
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
removed to the nursery for routine care or testing. The father or other designated
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
members of the mother‘s support system are encouraged to stay at all times.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: gg gg g g gg gg
Assessment MSC: Patient Needs: Health Promotion and Maintenance
gg gg g g gg gg gg gg gg
4. Which nursing intervention is an independent function of the professional nurse?
gg gg gg gg gg gg gg gg gg gg
a. Administering oral analgesics gg gg
b. Requesting diagnostic studies gg gg
c. Teaching the patient perineal care gg gg gg gg
d. Providing wound care to a surgical gg gg gg gg gg
gg incision
ANS: g g C
Nurses are now responsible for various independent functions, including teaching,
gg gg gg gg gg gg gg gg gg
counseling, and intervening in nonmedical problems. Interventions initiated by the
gg gg gg gg gg gg gg gg gg gg
physician and carried out by the nurse are called dependent functions. Administrating
gg gg gg gg gg gg gg gg gg gg gg gg
oral analgesics is a dependent function; it is initiated by a physician and carried out
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
by a nurse. Requesting diagnostic studies is a dependent function. Providing wound
gg gg gg gg gg gg gg gg gg gg gg gg
care is a dependent function; however, the physician prescribes the type of wound
gg gg gg gg gg gg gg gg gg gg gg gg gg
care through direct orders or protocol.
gg gg gg gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: gg gg g g gg gg
Assessment MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
5. Which response by the nurse is the most therapeutic when the patient states, ―I‘m so
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
afraid to have a cesarean birth‖?
gg gg gg gg gg gg
a. ―Everything will be OK.‖ gg gg gg
b. ―Don‘t worry about it. It will be over soon.‖ gg gg gg gg gg gg gg gg
c. ―What concerns you most about a cesarean birth?‖
gg gg gg gg gg gg gg
d. ―The physician will be in later and you can talk to
gg gg gg gg gg gg gg gg gg gg
him.‖
gg
ANS: g g C
The response, ―What concerns you most about a cesarean birth‖ focuses on what
gg gg gg gg gg gg gg gg gg gg gg gg
the patient is saying and asks for clarification, which is the most therapeutic
gg gg gg gg gg gg gg gg gg gg gg gg gg
response. The response, ―Everything will be ok‖ is belittling the patient‘s feelings. The
gg gg gg gg gg gg gg gg gg gg gg gg gg
response, ―Don‘t worry about it. It will be over soon‖ will indicate that the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
patient‘s feelings are not important. The response, ―The physician will be in later
gg gg gg gg gg gg gg gg gg gg gg gg gg
and you can talk to him‖ does not allow the patient to verbalize her feelings when
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
she wishes to do that.
gg gg gg gg gg
DIF: Cognitive Level: Application gg gg OBJ: gg gg Nursing Process Step: Implementation gg gg gg
, MSC: g g Patient Needs: Psychosocial Integrity
gg gg gg
6. In which step of the nursing process does the nurse determine the appropriate
gg gg gg gg gg gg gg gg gg gg gg gg
interventions for the identified nursing diagnosis?
gg gg gg gg gg gg
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: g g A
The third step in the nursing process involves planning care for problems that were
gg gg gg gg gg gg gg gg gg gg gg gg gg
identified during assessment. The evaluation phase is determining whether the goals
gg gg gg gg gg gg gg gg gg gg gg
have been met. During the assessment phase, data are collected. The intervention
gg gg gg gg gg gg gg gg gg gg gg gg
phase is when the plan of care is carried out.
gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step:
gg gg g g gg gg
Planning MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
7. Which goal is most appropriate for the collaborative problem of wound infection?
gg gg gg gg gg gg gg gg gg gg gg
a. The patient will not exhibit further signs of infection.
gg gg gg gg gg gg gg gg
b. Maintain the patient‘s fluid intake at 1000 mL/8 hour.
gg gg gg gg gg gg gg gg
c. The patient will have a temperature of 98.F within 2 days.
gg gg gg gg gg gg gg gg gg gg
d. Monitor the patient to detect therapeutic response to antibiotic
gg gg gg gg gg gg gg gg
therapy.
gg
ANS: g g D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
gg gg gg gg gg gg gg gg gg gg gg gg
interventions of monitoring or observing. Monitoring for complications such as
gg gg gg gg gg gg gg gg gg gg
further signs of infection is an independent nursing role. Intake and output is an
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
independent nursing role. Monitoring a patient‘s temperature is an independent
gg gg gg gg gg gg gg gg gg gg
nursing role.
gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step:
gg gg g g gg gg
Planning MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
8. Which nursing intervention is written correctly?
gg gg gg gg gg
a. Force fluids as necessary. gg gg gg
b. Observe interaction with the infant. gg gg gg gg
c. Encourage turning, coughing, and deep breathing. gg gg gg gg gg
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6
gg gg gg gg gg gg gg gg gg gg gg gg
PM.
gg
ANS: g g D
Interventions might not be carried out if they are not detailed and specific. ―Force
gg gg gg gg gg gg gg gg gg gg gg gg gg
fluids‖ is not specific; it does not state how much or how often. Encouraging the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
patient to turn, cough, and breathe deeply is not detailed or specific. Observing
gg gg gg gg gg gg gg gg gg gg gg gg gg
interaction with the infant does not state how often this procedure should be done.
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
Assisting the patient to ambulate for 10 minutes within a certain timeframe is
gg gg gg gg gg gg gg gg gg gg gg gg gg
specific.
gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step:
gg gg g g gg gg
Planning MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
, 9. The patient makes the statement: ―I‘m afraid to take the baby home tomorrow.‖
gg gg gg gg gg gg gg gg gg gg gg gg
Which response by the nurse would be the most therapeutic?
gg gg gg gg gg gg gg gg gg gg
a. ―You‘re afraid to take the baby gg gg gg gg gg
home?‖
gg
b. ―Don‘t you have a mother who can come and help?‖ gg gg gg gg gg gg gg gg gg
c. ―You should read the literature I gave you before you leave.‖
gg gg gg gg gg gg gg gg gg gg
d. ―I was scared when I took my first baby home, but everything worked
gg gg gg gg gg gg gg gg gg gg gg gg
out.‖
gg
ANS: g g A
This response uses reflection to show concern and open communication. The other
gg gg gg gg gg gg gg gg gg gg gg
choices are blocks to communication. Asking if the patient has a mother who can
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
come and assist blocks further communication with the patient. Telling the patient to
gg gg gg gg gg gg gg gg gg gg gg gg gg
read the literature before leaving does not allow the patient to express her feelings
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
further. Sharing your own birth experience is inappropriate.
gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step: gg gg g g gg gg
Implementation MSC: Patient Needs: Psychosocial Integrity
gg gg g g gg gg gg
10. The nurse is writing an expected outcome for the nursing diagnosis—acute pain
gg gg gg gg gg gg gg gg gg gg gg
related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating
gg gg gg gg gg gg gg gg gg gg gg gg gg
pain of 8 on a scale of 10. Which expected outcome is correctly stated for this
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
problem?
gg
a. Patient will state that pain is a 2 on a scale of 10.
gg gg gg gg gg gg gg gg gg gg gg gg
b. Patient will have a reduction in pain after administration of the prescribed
gg gg gg gg gg gg gg gg gg gg gg
analgesic.
c. Patient will state an absence of pain 1 hour after administration of the
gg gg gg gg gg gg gg gg gg gg gg gg
prescribed
gg
analgesic.
d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
administration of
gg gg
the prescribed analgesic.
gg gg
ANS: g g D
The outcome should be patient-centered, measurable, realistic, and attainable and
gg gg gg gg gg gg gg gg gg
within a specified timeframe. Patient stating that her pain is now 2 on a scale of 10
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
lacks a timeframe. Patient having a reduction in pain after administration of the
gg gg gg gg gg gg gg gg gg gg gg gg gg
prescribed analgesic lacks a measurement. Patient stating an absence of pain 1 hour
gg gg gg gg gg gg gg gg gg gg gg gg gg
after the administration of prescribed analgesic is unrealistic.
gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step: gg gg g g gg gg
Planning MSC: Patient Needs: Physiologic Integrity
gg gg g g gg gg gg
11. Which nursing diagnosis should the nurse identify as a priority for a patient in
gg gg gg gg gg gg gg gg gg gg gg gg gg
gg active labor? gg
a. Risk for anxiety related to upcoming birth
gg gg gg gg gg gg
b. Risk for imbalanced nutrition related to NPO status
gg gg gg gg gg gg gg
c. Risk for altered family processes related to new addition to the family
gg gg gg gg gg gg gg gg gg gg gg
d. Risk for injury (maternal) related to altered sensations and positional or
gg gg gg gg gg gg gg gg gg gg
physical
gg
changes
Murray Foundations of Maternal-Newborn and Women's Health Nursing,
gg gg gg gg gg gg gg
8th Edition
gg gg
Chapter 01: gg
MULTIPLE CHOICE gg
1. A nurse educator is teaching a group of nursing students about the history of
gg gg gg gg gg gg gg gg gg gg gg gg gg
family-centered maternity care. Which statement should the nurse include in the teaching
gg gg gg gg gg gg gg gg gg gg gg
session?
gg
a. The Sheppard-Towner Act of 1921 promoted family-centered care.
gg gg gg gg gg gg gg
b. Changes in pharmacologic management of labor prompted family-centered
gg gg gg gg gg gg gg
care. gg
c. Demands by physicians for family involvement in childbirth increased the
gg gg gg gg gg gg gg gg gg
practice gg
of family-centered care.
gg gg
d. Parental requests that infants be allowed to remain with them rather than in a
gg gg gg gg gg gg gg gg gg gg gg gg gg
nursery initiated the practice of family-centered care.
gg gg gg gg gg gg
ANS: g g D
As research began to identify the benefits of early, extended parent–infant contact,
gg gg gg gg gg gg gg gg gg gg gg
parents began to insist that the infant remain with them. This gradually developed
gg gg gg gg gg gg gg gg gg gg gg gg gg
into the practice of rooming-in and finally to family-centered maternity care. The
gg gg gg gg gg gg gg gg gg gg gg gg
Sheppard-Towner Act provided funds for state-managed programs for mothers and
gg gg gg gg gg gg gg gg gg gg
children but did not promote family-centered care. The changes in pharmacologic
gg gg gg gg gg gg gg gg gg gg gg
management of labor were not a factor in family-centered maternity care. Family-
gg gg gg gg gg gg gg gg gg gg gg gg
centered care was a request by parents, not physicians.
gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step: gg gg g g gg gg
Planning MSC: Patient Needs: Health Promotion and Maintenance
gg gg g g gg gg gg gg gg
2. Expectant parents ask a prenatal nurse educator, ―Which setting for childbirth limits
gg gg gg gg gg gg gg gg gg gg gg
the amount of parent–infant interaction?‖ Which answer should the nurse provide
gg gg gg gg gg gg gg gg gg gg gg
for these parents in order to assist them in choosing an appropriate birth setting?
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
a. Birth center gg
b. Home birth gg
c. Traditional hospital birth gg gg
d. Labor, birth, and recovery gg gg gg
room gg
ANS: g g C
In the traditional hospital setting, the mother may see the infant for only short
gg gg gg gg gg gg gg gg gg gg gg gg gg
feeding periods, and the infant is cared for in a separate nursery. Birth centers are
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
set up to allow an increase in parent–infant contact. Home births allow the greatest
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
amount of
gg gg
parent–infant contact. The labor, birth, recovery, and postpartum room setting allows for
gg gg gg gg gg gg gg gg gg gg gg
increased parent–infant contact.
gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: gg gg g g gg gg
Planning MSC: Patient Needs: Health Promotion and Maintenance
gg gg g g gg gg gg gg gg
,3. Which statement best describes the advantage of a labor, birth, recovery, and
gg gg gg gg gg gg gg gg gg gg gg
gg postpartum (LDRP) room? gg gg
a. The family is in a familiar environment.
gg gg gg gg gg gg
b. They are less expensive than traditional hospital rooms.
gg gg gg gg gg gg gg
c. The infant is removed to the nursery to allow the mother to
gg gg gg gg gg gg gg gg gg gg gg
rest.
gg
d. The woman‘s support system is encouraged to stay until
gg gg gg gg gg gg gg gg
discharge.
gg
ANS: g g D
Sleeping equipment is provided in a private room. A hospital setting is never a
gg gg gg gg gg gg gg gg gg gg gg gg gg
familiar environment to new parents. An LDRP room is not less expensive than a
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
traditional hospital room. The baby remains with the mother at all times and is not
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
removed to the nursery for routine care or testing. The father or other designated
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
members of the mother‘s support system are encouraged to stay at all times.
gg gg gg gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: gg gg g g gg gg
Assessment MSC: Patient Needs: Health Promotion and Maintenance
gg gg g g gg gg gg gg gg
4. Which nursing intervention is an independent function of the professional nurse?
gg gg gg gg gg gg gg gg gg gg
a. Administering oral analgesics gg gg
b. Requesting diagnostic studies gg gg
c. Teaching the patient perineal care gg gg gg gg
d. Providing wound care to a surgical gg gg gg gg gg
gg incision
ANS: g g C
Nurses are now responsible for various independent functions, including teaching,
gg gg gg gg gg gg gg gg gg
counseling, and intervening in nonmedical problems. Interventions initiated by the
gg gg gg gg gg gg gg gg gg gg
physician and carried out by the nurse are called dependent functions. Administrating
gg gg gg gg gg gg gg gg gg gg gg gg
oral analgesics is a dependent function; it is initiated by a physician and carried out
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
by a nurse. Requesting diagnostic studies is a dependent function. Providing wound
gg gg gg gg gg gg gg gg gg gg gg gg
care is a dependent function; however, the physician prescribes the type of wound
gg gg gg gg gg gg gg gg gg gg gg gg gg
care through direct orders or protocol.
gg gg gg gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: gg gg g g gg gg
Assessment MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
5. Which response by the nurse is the most therapeutic when the patient states, ―I‘m so
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
afraid to have a cesarean birth‖?
gg gg gg gg gg gg
a. ―Everything will be OK.‖ gg gg gg
b. ―Don‘t worry about it. It will be over soon.‖ gg gg gg gg gg gg gg gg
c. ―What concerns you most about a cesarean birth?‖
gg gg gg gg gg gg gg
d. ―The physician will be in later and you can talk to
gg gg gg gg gg gg gg gg gg gg
him.‖
gg
ANS: g g C
The response, ―What concerns you most about a cesarean birth‖ focuses on what
gg gg gg gg gg gg gg gg gg gg gg gg
the patient is saying and asks for clarification, which is the most therapeutic
gg gg gg gg gg gg gg gg gg gg gg gg gg
response. The response, ―Everything will be ok‖ is belittling the patient‘s feelings. The
gg gg gg gg gg gg gg gg gg gg gg gg gg
response, ―Don‘t worry about it. It will be over soon‖ will indicate that the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
patient‘s feelings are not important. The response, ―The physician will be in later
gg gg gg gg gg gg gg gg gg gg gg gg gg
and you can talk to him‖ does not allow the patient to verbalize her feelings when
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
she wishes to do that.
gg gg gg gg gg
DIF: Cognitive Level: Application gg gg OBJ: gg gg Nursing Process Step: Implementation gg gg gg
, MSC: g g Patient Needs: Psychosocial Integrity
gg gg gg
6. In which step of the nursing process does the nurse determine the appropriate
gg gg gg gg gg gg gg gg gg gg gg gg
interventions for the identified nursing diagnosis?
gg gg gg gg gg gg
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: g g A
The third step in the nursing process involves planning care for problems that were
gg gg gg gg gg gg gg gg gg gg gg gg gg
identified during assessment. The evaluation phase is determining whether the goals
gg gg gg gg gg gg gg gg gg gg gg
have been met. During the assessment phase, data are collected. The intervention
gg gg gg gg gg gg gg gg gg gg gg gg
phase is when the plan of care is carried out.
gg gg gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Understanding OBJ: Nursing Process Step:
gg gg g g gg gg
Planning MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
7. Which goal is most appropriate for the collaborative problem of wound infection?
gg gg gg gg gg gg gg gg gg gg gg
a. The patient will not exhibit further signs of infection.
gg gg gg gg gg gg gg gg
b. Maintain the patient‘s fluid intake at 1000 mL/8 hour.
gg gg gg gg gg gg gg gg
c. The patient will have a temperature of 98.F within 2 days.
gg gg gg gg gg gg gg gg gg gg
d. Monitor the patient to detect therapeutic response to antibiotic
gg gg gg gg gg gg gg gg
therapy.
gg
ANS: g g D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
gg gg gg gg gg gg gg gg gg gg gg gg
interventions of monitoring or observing. Monitoring for complications such as
gg gg gg gg gg gg gg gg gg gg
further signs of infection is an independent nursing role. Intake and output is an
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
independent nursing role. Monitoring a patient‘s temperature is an independent
gg gg gg gg gg gg gg gg gg gg
nursing role.
gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step:
gg gg g g gg gg
Planning MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
8. Which nursing intervention is written correctly?
gg gg gg gg gg
a. Force fluids as necessary. gg gg gg
b. Observe interaction with the infant. gg gg gg gg
c. Encourage turning, coughing, and deep breathing. gg gg gg gg gg
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6
gg gg gg gg gg gg gg gg gg gg gg gg
PM.
gg
ANS: g g D
Interventions might not be carried out if they are not detailed and specific. ―Force
gg gg gg gg gg gg gg gg gg gg gg gg gg
fluids‖ is not specific; it does not state how much or how often. Encouraging the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
patient to turn, cough, and breathe deeply is not detailed or specific. Observing
gg gg gg gg gg gg gg gg gg gg gg gg gg
interaction with the infant does not state how often this procedure should be done.
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
Assisting the patient to ambulate for 10 minutes within a certain timeframe is
gg gg gg gg gg gg gg gg gg gg gg gg gg
specific.
gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step:
gg gg g g gg gg
Planning MSC: Patient Needs: Safe and Effective Care Environment
gg gg g g gg gg gg gg gg gg
, 9. The patient makes the statement: ―I‘m afraid to take the baby home tomorrow.‖
gg gg gg gg gg gg gg gg gg gg gg gg
Which response by the nurse would be the most therapeutic?
gg gg gg gg gg gg gg gg gg gg
a. ―You‘re afraid to take the baby gg gg gg gg gg
home?‖
gg
b. ―Don‘t you have a mother who can come and help?‖ gg gg gg gg gg gg gg gg gg
c. ―You should read the literature I gave you before you leave.‖
gg gg gg gg gg gg gg gg gg gg
d. ―I was scared when I took my first baby home, but everything worked
gg gg gg gg gg gg gg gg gg gg gg gg
out.‖
gg
ANS: g g A
This response uses reflection to show concern and open communication. The other
gg gg gg gg gg gg gg gg gg gg gg
choices are blocks to communication. Asking if the patient has a mother who can
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
come and assist blocks further communication with the patient. Telling the patient to
gg gg gg gg gg gg gg gg gg gg gg gg gg
read the literature before leaving does not allow the patient to express her feelings
gg gg gg gg gg gg gg gg gg gg gg gg gg gg
further. Sharing your own birth experience is inappropriate.
gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step: gg gg g g gg gg
Implementation MSC: Patient Needs: Psychosocial Integrity
gg gg g g gg gg gg
10. The nurse is writing an expected outcome for the nursing diagnosis—acute pain
gg gg gg gg gg gg gg gg gg gg gg
related to tissue trauma, secondary to vaginal birth, as evidenced by patient stating
gg gg gg gg gg gg gg gg gg gg gg gg gg
pain of 8 on a scale of 10. Which expected outcome is correctly stated for this
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
problem?
gg
a. Patient will state that pain is a 2 on a scale of 10.
gg gg gg gg gg gg gg gg gg gg gg gg
b. Patient will have a reduction in pain after administration of the prescribed
gg gg gg gg gg gg gg gg gg gg gg
analgesic.
c. Patient will state an absence of pain 1 hour after administration of the
gg gg gg gg gg gg gg gg gg gg gg gg
prescribed
gg
analgesic.
d. Patient will state that pain is a 2 on a scale of 10, 1 hour after the
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
administration of
gg gg
the prescribed analgesic.
gg gg
ANS: g g D
The outcome should be patient-centered, measurable, realistic, and attainable and
gg gg gg gg gg gg gg gg gg
within a specified timeframe. Patient stating that her pain is now 2 on a scale of 10
gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg gg
lacks a timeframe. Patient having a reduction in pain after administration of the
gg gg gg gg gg gg gg gg gg gg gg gg gg
prescribed analgesic lacks a measurement. Patient stating an absence of pain 1 hour
gg gg gg gg gg gg gg gg gg gg gg gg gg
after the administration of prescribed analgesic is unrealistic.
gg gg gg gg gg gg gg gg
DIF: Cognitive Level: Application OBJ: Nursing Process Step: gg gg g g gg gg
Planning MSC: Patient Needs: Physiologic Integrity
gg gg g g gg gg gg
11. Which nursing diagnosis should the nurse identify as a priority for a patient in
gg gg gg gg gg gg gg gg gg gg gg gg gg
gg active labor? gg
a. Risk for anxiety related to upcoming birth
gg gg gg gg gg gg
b. Risk for imbalanced nutrition related to NPO status
gg gg gg gg gg gg gg
c. Risk for altered family processes related to new addition to the family
gg gg gg gg gg gg gg gg gg gg gg
d. Risk for injury (maternal) related to altered sensations and positional or
gg gg gg gg gg gg gg gg gg gg
physical
gg
changes
