FOUNDATIONS OF MATERNAL-
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1. Clinical Judgment and the Nursing Process — Prioritizing
Abnormal Findings
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem: A laboring client at 39 weeks reports a sudden gush of
fluid. The LPN notes the fluid is green-tinged, and the fetal
heart rate on the monitor has dropped to 94/min after a
contraction. Which action should the LPN take first?
A. Encourage the client to walk to help labor progress
B. Notify the RN immediately and stay with the client
,C. Recheck the fetal heart rate in 30 minutes
D. Offer the client ice chips and document the finding
Correct Answer: B
Rationale — Correct Answer: Green-tinged fluid and a fetal
heart rate below the expected range after a contraction are
abnormal findings that may indicate fetal compromise. The LPN
should report immediately to the RN and remain with the client
to support safety and prompt intervention. This reflects clinical
judgment and appropriate escalation within LPN scope.
Rationale — Incorrect Options:
A. Ambulation is not appropriate when fetal status is abnormal
and needs urgent follow-up.
C. Waiting 30 minutes delays needed intervention and ignores a
priority change in status.
D. Ice chips and documentation do not address the priority
safety concern.
Teaching Point: Abnormal fetal heart findings require
immediate reporting, not delayed reassessment.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
2. Clinical Judgment and the Nursing Process — Recognizing
Priority Postpartum Care
,Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem: Four hours after birth, a postpartum client reports
dizziness when sitting up. The LPN finds the client pale with a
pulse of 118/min and a saturated perineal pad. Which action is
best?
A. Encourage the client to walk to the bathroom to improve
circulation
B. Assess the fundus and notify the RN immediately
C. Tell the client that dizziness is expected after delivery
D. Reassess the client at the next scheduled vital sign check
Correct Answer: B
Rationale — Correct Answer: Dizziness, tachycardia, pallor, and
heavy bleeding suggest possible postpartum hemorrhage. The
LPN should assess the fundus and report promptly so the RN
can initiate further management. This is a priority safety action.
Rationale — Incorrect Options:
A. Ambulation is unsafe when bleeding and instability are
present.
C. Dismissing the findings delays treatment of a potentially
urgent problem.
D. Waiting can worsen maternal instability and blood loss.
Teaching Point: Heavy bleeding with tachycardia is an urgent
postpartum warning sign.
, Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
3. Clinical Judgment and the Nursing Process — Reporting
Hypertensive Warning Signs
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem: At a prenatal visit, a client at 34 weeks’ gestation reports
a severe headache and spots in her vision. Her blood pressure is
162/102 mm Hg. What should the LPN do first?
A. Ask the client to return in one week for a repeat blood
pressure
B. Provide routine pregnancy teaching about weight gain
C. Notify the RN or provider immediately
D. Reassure the client that these symptoms are common in late
pregnancy
Correct Answer: C
Rationale — Correct Answer: Severe headache, visual changes,
and markedly elevated blood pressure are danger signs of
preeclampsia. The LPN must report immediately because timely
evaluation is essential for maternal and fetal safety. This is a
high-priority abnormal assessment.
Rationale — Incorrect Options:
A. Delaying follow-up is unsafe with severe hypertension and
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1. Clinical Judgment and the Nursing Process — Prioritizing
Abnormal Findings
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem: A laboring client at 39 weeks reports a sudden gush of
fluid. The LPN notes the fluid is green-tinged, and the fetal
heart rate on the monitor has dropped to 94/min after a
contraction. Which action should the LPN take first?
A. Encourage the client to walk to help labor progress
B. Notify the RN immediately and stay with the client
,C. Recheck the fetal heart rate in 30 minutes
D. Offer the client ice chips and document the finding
Correct Answer: B
Rationale — Correct Answer: Green-tinged fluid and a fetal
heart rate below the expected range after a contraction are
abnormal findings that may indicate fetal compromise. The LPN
should report immediately to the RN and remain with the client
to support safety and prompt intervention. This reflects clinical
judgment and appropriate escalation within LPN scope.
Rationale — Incorrect Options:
A. Ambulation is not appropriate when fetal status is abnormal
and needs urgent follow-up.
C. Waiting 30 minutes delays needed intervention and ignores a
priority change in status.
D. Ice chips and documentation do not address the priority
safety concern.
Teaching Point: Abnormal fetal heart findings require
immediate reporting, not delayed reassessment.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
2. Clinical Judgment and the Nursing Process — Recognizing
Priority Postpartum Care
,Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem: Four hours after birth, a postpartum client reports
dizziness when sitting up. The LPN finds the client pale with a
pulse of 118/min and a saturated perineal pad. Which action is
best?
A. Encourage the client to walk to the bathroom to improve
circulation
B. Assess the fundus and notify the RN immediately
C. Tell the client that dizziness is expected after delivery
D. Reassess the client at the next scheduled vital sign check
Correct Answer: B
Rationale — Correct Answer: Dizziness, tachycardia, pallor, and
heavy bleeding suggest possible postpartum hemorrhage. The
LPN should assess the fundus and report promptly so the RN
can initiate further management. This is a priority safety action.
Rationale — Incorrect Options:
A. Ambulation is unsafe when bleeding and instability are
present.
C. Dismissing the findings delays treatment of a potentially
urgent problem.
D. Waiting can worsen maternal instability and blood loss.
Teaching Point: Heavy bleeding with tachycardia is an urgent
postpartum warning sign.
, Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
3. Clinical Judgment and the Nursing Process — Reporting
Hypertensive Warning Signs
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem: At a prenatal visit, a client at 34 weeks’ gestation reports
a severe headache and spots in her vision. Her blood pressure is
162/102 mm Hg. What should the LPN do first?
A. Ask the client to return in one week for a repeat blood
pressure
B. Provide routine pregnancy teaching about weight gain
C. Notify the RN or provider immediately
D. Reassure the client that these symptoms are common in late
pregnancy
Correct Answer: C
Rationale — Correct Answer: Severe headache, visual changes,
and markedly elevated blood pressure are danger signs of
preeclampsia. The LPN must report immediately because timely
evaluation is essential for maternal and fetal safety. This is a
high-priority abnormal assessment.
Rationale — Incorrect Options:
A. Delaying follow-up is unsafe with severe hypertension and
