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: Clinical Judgment and the Nursing Process —
Nursing Process: Assessment
,Stem: A nurse is admitting a 32-year-old primigravida at 38
weeks gestation to the labor and birth unit. The client states, "I
think my water broke about two hours ago, but I'm not sure."
Which action should the nurse take first?
Options:
A. Obtain a baseline fetal heart rate
B. Assess the client's vital signs
C. Perform a sterile speculum examination
D. Review the client's prenatal records
Correct Answer: C. Perform a sterile speculum examination
Rationale for Correct Answer: Assessment is the first step of
the nursing process and involves collecting comprehensive data
to identify client needs. In this scenario, the client reports
possible rupture of membranes, which requires immediate
confirmation through a sterile speculum examination to
visualize the cervix and assess for fluid pooling, ferning, and
nitrazine testing. This objective data collection is essential
before implementing other nursing actions and establishes the
baseline for subsequent care decisions.
Rationale for Incorrect Options:
• A. Obtain a baseline fetal heart rate: While fetal
assessment is important, confirming membrane status
takes priority to determine the plan of care. Fetal heart
, rate assessment would occur after or concurrently with
membrane confirmation.
• B. Assess the client's vital signs: Vital signs are part of the
admission assessment but do not directly address the
client's reported concern about ruptured membranes. This
action would be appropriate but not the priority.
• D. Review the client's prenatal records: Although
reviewing records provides valuable information, the
immediate clinical priority is to assess the client's current
status. Obtaining records would not address the need to
confirm membrane status.
Teaching Point: Complete a thorough nursing assessment to
confirm client reports before determining priority interventions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process — Nursing Process: Assessment.
Question 2
Reference: Clinical Judgment and the Nursing Process — Critical
Thinking in Nursing
Stem: A postpartum nurse is caring for a client who delivered
12 hours ago. The client reports a "gush of fluid" and the nurse
notes a fundus that is firm and midline at the umbilicus. The
, perineal pad is saturated with bright red blood. Which action
demonstrates critical thinking?
Options:
A. Document the findings and continue to monitor
B. Encourage the client to ambulate to promote drainage
C. Notify the healthcare provider immediately
D. Massage the fundus and assess for clots
Correct Answer: D. Massage the fundus and assess for clots
Rationale for Correct Answer: Critical thinking involves
recognizing cues, analyzing data, and generating solutions. The
nurse identifies that the firm fundus with bright red bleeding
suggests possible vaginal lacerations or retained clots rather
than uterine atony. Massaging the fundus helps expel clots that
may be trapped in the uterus and allows for further assessment
of bleeding. This demonstrates clinical reasoning by linking
assessment findings to an appropriate nursing action based on
the data collected.
Rationale for Incorrect Options:
• A. Document the findings and continue to monitor: This
passive response fails to address the active bleeding and
does not demonstrate critical thinking or prioritization of a
potential complication.
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: Clinical Judgment and the Nursing Process —
Nursing Process: Assessment
,Stem: A nurse is admitting a 32-year-old primigravida at 38
weeks gestation to the labor and birth unit. The client states, "I
think my water broke about two hours ago, but I'm not sure."
Which action should the nurse take first?
Options:
A. Obtain a baseline fetal heart rate
B. Assess the client's vital signs
C. Perform a sterile speculum examination
D. Review the client's prenatal records
Correct Answer: C. Perform a sterile speculum examination
Rationale for Correct Answer: Assessment is the first step of
the nursing process and involves collecting comprehensive data
to identify client needs. In this scenario, the client reports
possible rupture of membranes, which requires immediate
confirmation through a sterile speculum examination to
visualize the cervix and assess for fluid pooling, ferning, and
nitrazine testing. This objective data collection is essential
before implementing other nursing actions and establishes the
baseline for subsequent care decisions.
Rationale for Incorrect Options:
• A. Obtain a baseline fetal heart rate: While fetal
assessment is important, confirming membrane status
takes priority to determine the plan of care. Fetal heart
, rate assessment would occur after or concurrently with
membrane confirmation.
• B. Assess the client's vital signs: Vital signs are part of the
admission assessment but do not directly address the
client's reported concern about ruptured membranes. This
action would be appropriate but not the priority.
• D. Review the client's prenatal records: Although
reviewing records provides valuable information, the
immediate clinical priority is to assess the client's current
status. Obtaining records would not address the need to
confirm membrane status.
Teaching Point: Complete a thorough nursing assessment to
confirm client reports before determining priority interventions.
Citation: Murray, S. (2023). Foundations of Maternal-Newborn
and Women's Health Nursing (8th ed.). Clinical Judgment and
the Nursing Process — Nursing Process: Assessment.
Question 2
Reference: Clinical Judgment and the Nursing Process — Critical
Thinking in Nursing
Stem: A postpartum nurse is caring for a client who delivered
12 hours ago. The client reports a "gush of fluid" and the nurse
notes a fundus that is firm and midline at the umbilicus. The
, perineal pad is saturated with bright red blood. Which action
demonstrates critical thinking?
Options:
A. Document the findings and continue to monitor
B. Encourage the client to ambulate to promote drainage
C. Notify the healthcare provider immediately
D. Massage the fundus and assess for clots
Correct Answer: D. Massage the fundus and assess for clots
Rationale for Correct Answer: Critical thinking involves
recognizing cues, analyzing data, and generating solutions. The
nurse identifies that the firm fundus with bright red bleeding
suggests possible vaginal lacerations or retained clots rather
than uterine atony. Massaging the fundus helps expel clots that
may be trapped in the uterus and allows for further assessment
of bleeding. This demonstrates clinical reasoning by linking
assessment findings to an appropriate nursing action based on
the data collected.
Rationale for Incorrect Options:
• A. Document the findings and continue to monitor: This
passive response fails to address the active bleeding and
does not demonstrate critical thinking or prioritization of a
potential complication.
