Introductory Maternity and Pediatric Nursing 4th Edition Hatfield Test Bank
Chapter 1: The Nurse's Role in a Changing Maternal–Child Health Care Environment
MULTIPLE CHOICE
1. Which principle of teaching should the nurse use to ensure learning in a family situation?
a. Motivate the family with praise and positive feedback.
b. Learning is best accomplished with the lecture format.
c. Present complex subject material first while the family is alert and ready to learn.
ISBN 10: 1496346645 ISBN 13: 9781496346643 d. Families should be taught using medical jargon so they will be able to understand
the technical language used by physicians.
ANS: A
Praise and positive feedback are particularly important when a family is trying to master a
frustrating task such as breastfeeding. A lively discussion stimulates more learning than a
straight lecture, which tends to inhibit questions. Learning is enhanced when the teaching is
structured to present the simple tasks before the complex material. Even though a family may
understand English fairly well, they may not understand the medical terminology or slang terms
that are used.
PTS: 1 DIF: Cognitive Level: Application REF: 18, 19
OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
2. Which nursing intervention is an independent function of the nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the client perineal care
d. Providing wound care to a surgical incision
,ANS: C MSC: Client Needs: Psychosocial Integrity
Nurses are now responsible for various independent functions, including teaching, counseling, 4. Which action should the nurse take to evaluate the clients learning about performing infant
and intervening in nonmedical problems. Interventions initiated by the physician and carried out care?
by the nurse are called dependent functions. Administrating oral analgesics is a dependent
a. Demonstrate infant care procedures.
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is
a dependent function. Providing wound care is a dependent function; it is usually initiated by the b. Allow the client to verbalize the procedure.
physician through direct orders or protocol. c. Routinely assess the infant for cleanliness.
d. Observe the client as she performs the procedure.
PTS: 1 DIF: Cognitive Level: Understanding REF: 24
ANS: D
OBJ: Nursing Process Step: Assessment
The clients correct performance of the procedure under the nurses supervision is the best proof of
MSC: Client Needs: Safe and Effective Care Environment
her ability. Demonstration is an excellent teaching method, but not an evaluation method. During
3. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is
should be made by the nurse? not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that
the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being
a. Everything will be OK. used.
b. Dont worry about it. It will be over soon.
PTS: 1 DIF: Cognitive Level: Application REF: 21
c. What concerns you most about a cesarean birth?
d. The physician will be in later and you can talk to him. OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance
ANS: C 5. A nurse is reviewing teaching and learning principles. Which situation is most conducive to
learning?
The response, What concerns you most about a cesarean birth focuses on what the client is
saying and asks for clarification, which is the most therapeutic response. The response, a. An auditorium is being used as a classroom for 300 students.
Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
be over soon will indicate that the clients feelings are not important. The response, The physician c. A class is composed of students of various ages and educational backgrounds.
will be in later and you can talk to him does not allow the client to verbalize her feelings when
d. An Asian nurse provides nutritional information to a group of pregnant Asian
she wishes to do that. women.
PTS: 1 DIF: Cognitive Level: Application REF: 18
ANS: D
OBJ: Nursing Process Step: Implementation
,A clients culture influences the learning process; thus, a situation that is most conducive to 7. Which goal is most appropriate for the collaborative problem of wound infection?
learning is one in which the teacher has knowledge and understanding of the clients cultural
a. The client will not exhibit further signs of infection.
beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher
cannot see nonverbal cues from the students to ensure understanding. The ability to understand b. Maintain the clients fluid intake at 1000 mL/8 hr.
the language in which teaching is done determines how much the client learns. Clients for whom c. The client will have a temperature of 98.6 F within 2 days.
English is not their primary language may not understand idioms, nuances, slang terms, informed d. Monitor the client to detect therapeutic response to antibiotic therapy.
usage of words, or medical terms. The teacher should be fluent in the language of the student.
Developmental levels and educational levels influence how a person learns best. For the teacher ANS: D
to present the information in the best way, the class should be at the same level.
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
PTS: 1 DIF: Cognitive Level: Application REF: 20 interventions of monitoring or observing. Monitoring for complications such as further signs of
infection is an independent nursing role. Intake and output is an independent nursing role.
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
Monitoring a clients temperature is an independent nursing role.
6. Which is the step of the nursing process in which the nurse determines the appropriate
PTS: 1 DIF: Cognitive Level: Application REF: 18
interventions for the identified nursing diagnosis?
OBJ: Nursing Process Step: Planning
a. Planning
b. Evaluation MSC: Client Needs: Safe and Effective Care Environment
c. Assessment
8. Which nursing intervention is correctly written?
d. Intervention
a. Force fluids as necessary.
ANS: A b. Observe interaction with the infant.
The third step in the nursing process involves planning care for problems that were identified c. Encourage turning, coughing, and deep breathing.
during assessment. The evaluation phase is determining whether the goals have been met. During d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
the assessment phase, data are collected. The intervention phase is when the plan of care is
carried out. ANS: D
PTS: 1 DIF: Cognitive Level: Understanding REF: 24 Interventions might not be carried out if they are not detailed and specific. Force fluids is not
specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is
OBJ: Nursing Process Step: Planning not detailed and specific. Observing interaction with the infant does not state how often this
procedure should be done.
MSC: Client Needs: Safe and Effective Care Environment
PTS: 1 DIF: Cognitive Level: Application REF: 25
, OBJ: Nursing Process Step: Planning d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of
the prescribed analgesic.
MSC: Client Needs: Safe and Effective Care Environment
ANS: D
9. The client makes the statement: Im afraid to take the baby home tomorrow. Which response
by the nurse would be the most therapeutic? The outcome should be client-centered, measurable, realistic, and attainable and have a time
frame. Client stating that pain is now 2 on a scale of 10 lacks a time frame. Client having a
a. Youre afraid to take the baby home? reduction in pain after administration of the prescribed analgesic lacks a measurement. Client
b. Dont you have a mother who can come and help? stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic.
c. You should read the literature I gave you before you leave.
PTS: 1 DIF: Cognitive Level: Application REF: 25
d. I was scared when I took my first baby home, but everything worked out.
OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
ANS: A
11. Which nursing diagnosis should the nurse set as a priority for a laboring client?
This response uses reflection to show concern and open communication. The other choices are
blocks to communication. Asking if the client has a mother who can come and help blocks a. Risk for anxiety related to upcoming birth
further communication with the client. Telling the client to read the literature before leaving does b. Risk for imbalanced nutrition related to NPO status
not allow the client to express her feelings further. Sharing your feelings about your experience c. Risk for altered family processes related to new addition to the family
with a new baby blocks further communication with the client.
d. Risk for injury (maternal) related to altered sensations and positional or physical
changes
PTS: 1 DIF: Cognitive Level: Application REF: 18, 19
ANS: D
OBJ: Nursing Process Step: Implementation
The nurse should determine which problem needs immediate attention. Risk for injury is the
MSC: Client Needs: Psychosocial Integrity
problem that has the priority at this time because it is a safety problem. Risk for anxiety,
10. The nurse is writing an expected outcome for the nursing diagnosisacute pain related to imbalanced nutrition, and altered family processes are not the priorities at this time.
trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of
PTS: 1 DIF: Cognitive Level: Application REF: 24, 25
10. Which is a correctly stated expected outcome for this problem?
OBJ: Nursing Process Step: Implementation
a. Client will state that pain is a 2 on a scale of 10.
b. Client will have a reduction in pain after administration of the prescribed MSC: Client Needs: Safe and Effective Care Environment
analgesic.
c. Client will state an absence of pain 1 hour after administration of the prescribed 12. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
analgesic.
Chapter 1: The Nurse's Role in a Changing Maternal–Child Health Care Environment
MULTIPLE CHOICE
1. Which principle of teaching should the nurse use to ensure learning in a family situation?
a. Motivate the family with praise and positive feedback.
b. Learning is best accomplished with the lecture format.
c. Present complex subject material first while the family is alert and ready to learn.
ISBN 10: 1496346645 ISBN 13: 9781496346643 d. Families should be taught using medical jargon so they will be able to understand
the technical language used by physicians.
ANS: A
Praise and positive feedback are particularly important when a family is trying to master a
frustrating task such as breastfeeding. A lively discussion stimulates more learning than a
straight lecture, which tends to inhibit questions. Learning is enhanced when the teaching is
structured to present the simple tasks before the complex material. Even though a family may
understand English fairly well, they may not understand the medical terminology or slang terms
that are used.
PTS: 1 DIF: Cognitive Level: Application REF: 18, 19
OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
2. Which nursing intervention is an independent function of the nurse?
a. Administering oral analgesics
b. Requesting diagnostic studies
c. Teaching the client perineal care
d. Providing wound care to a surgical incision
,ANS: C MSC: Client Needs: Psychosocial Integrity
Nurses are now responsible for various independent functions, including teaching, counseling, 4. Which action should the nurse take to evaluate the clients learning about performing infant
and intervening in nonmedical problems. Interventions initiated by the physician and carried out care?
by the nurse are called dependent functions. Administrating oral analgesics is a dependent
a. Demonstrate infant care procedures.
function; it is initiated by a physician and carried out by a nurse. Requesting diagnostic studies is
a dependent function. Providing wound care is a dependent function; it is usually initiated by the b. Allow the client to verbalize the procedure.
physician through direct orders or protocol. c. Routinely assess the infant for cleanliness.
d. Observe the client as she performs the procedure.
PTS: 1 DIF: Cognitive Level: Understanding REF: 24
ANS: D
OBJ: Nursing Process Step: Assessment
The clients correct performance of the procedure under the nurses supervision is the best proof of
MSC: Client Needs: Safe and Effective Care Environment
her ability. Demonstration is an excellent teaching method, but not an evaluation method. During
3. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is
should be made by the nurse? not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that
the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being
a. Everything will be OK. used.
b. Dont worry about it. It will be over soon.
PTS: 1 DIF: Cognitive Level: Application REF: 21
c. What concerns you most about a cesarean birth?
d. The physician will be in later and you can talk to him. OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance
ANS: C 5. A nurse is reviewing teaching and learning principles. Which situation is most conducive to
learning?
The response, What concerns you most about a cesarean birth focuses on what the client is
saying and asks for clarification, which is the most therapeutic response. The response, a. An auditorium is being used as a classroom for 300 students.
Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
be over soon will indicate that the clients feelings are not important. The response, The physician c. A class is composed of students of various ages and educational backgrounds.
will be in later and you can talk to him does not allow the client to verbalize her feelings when
d. An Asian nurse provides nutritional information to a group of pregnant Asian
she wishes to do that. women.
PTS: 1 DIF: Cognitive Level: Application REF: 18
ANS: D
OBJ: Nursing Process Step: Implementation
,A clients culture influences the learning process; thus, a situation that is most conducive to 7. Which goal is most appropriate for the collaborative problem of wound infection?
learning is one in which the teacher has knowledge and understanding of the clients cultural
a. The client will not exhibit further signs of infection.
beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher
cannot see nonverbal cues from the students to ensure understanding. The ability to understand b. Maintain the clients fluid intake at 1000 mL/8 hr.
the language in which teaching is done determines how much the client learns. Clients for whom c. The client will have a temperature of 98.6 F within 2 days.
English is not their primary language may not understand idioms, nuances, slang terms, informed d. Monitor the client to detect therapeutic response to antibiotic therapy.
usage of words, or medical terms. The teacher should be fluent in the language of the student.
Developmental levels and educational levels influence how a person learns best. For the teacher ANS: D
to present the information in the best way, the class should be at the same level.
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
PTS: 1 DIF: Cognitive Level: Application REF: 20 interventions of monitoring or observing. Monitoring for complications such as further signs of
infection is an independent nursing role. Intake and output is an independent nursing role.
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
Monitoring a clients temperature is an independent nursing role.
6. Which is the step of the nursing process in which the nurse determines the appropriate
PTS: 1 DIF: Cognitive Level: Application REF: 18
interventions for the identified nursing diagnosis?
OBJ: Nursing Process Step: Planning
a. Planning
b. Evaluation MSC: Client Needs: Safe and Effective Care Environment
c. Assessment
8. Which nursing intervention is correctly written?
d. Intervention
a. Force fluids as necessary.
ANS: A b. Observe interaction with the infant.
The third step in the nursing process involves planning care for problems that were identified c. Encourage turning, coughing, and deep breathing.
during assessment. The evaluation phase is determining whether the goals have been met. During d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
the assessment phase, data are collected. The intervention phase is when the plan of care is
carried out. ANS: D
PTS: 1 DIF: Cognitive Level: Understanding REF: 24 Interventions might not be carried out if they are not detailed and specific. Force fluids is not
specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is
OBJ: Nursing Process Step: Planning not detailed and specific. Observing interaction with the infant does not state how often this
procedure should be done.
MSC: Client Needs: Safe and Effective Care Environment
PTS: 1 DIF: Cognitive Level: Application REF: 25
, OBJ: Nursing Process Step: Planning d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of
the prescribed analgesic.
MSC: Client Needs: Safe and Effective Care Environment
ANS: D
9. The client makes the statement: Im afraid to take the baby home tomorrow. Which response
by the nurse would be the most therapeutic? The outcome should be client-centered, measurable, realistic, and attainable and have a time
frame. Client stating that pain is now 2 on a scale of 10 lacks a time frame. Client having a
a. Youre afraid to take the baby home? reduction in pain after administration of the prescribed analgesic lacks a measurement. Client
b. Dont you have a mother who can come and help? stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic.
c. You should read the literature I gave you before you leave.
PTS: 1 DIF: Cognitive Level: Application REF: 25
d. I was scared when I took my first baby home, but everything worked out.
OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
ANS: A
11. Which nursing diagnosis should the nurse set as a priority for a laboring client?
This response uses reflection to show concern and open communication. The other choices are
blocks to communication. Asking if the client has a mother who can come and help blocks a. Risk for anxiety related to upcoming birth
further communication with the client. Telling the client to read the literature before leaving does b. Risk for imbalanced nutrition related to NPO status
not allow the client to express her feelings further. Sharing your feelings about your experience c. Risk for altered family processes related to new addition to the family
with a new baby blocks further communication with the client.
d. Risk for injury (maternal) related to altered sensations and positional or physical
changes
PTS: 1 DIF: Cognitive Level: Application REF: 18, 19
ANS: D
OBJ: Nursing Process Step: Implementation
The nurse should determine which problem needs immediate attention. Risk for injury is the
MSC: Client Needs: Psychosocial Integrity
problem that has the priority at this time because it is a safety problem. Risk for anxiety,
10. The nurse is writing an expected outcome for the nursing diagnosisacute pain related to imbalanced nutrition, and altered family processes are not the priorities at this time.
trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of
PTS: 1 DIF: Cognitive Level: Application REF: 24, 25
10. Which is a correctly stated expected outcome for this problem?
OBJ: Nursing Process Step: Implementation
a. Client will state that pain is a 2 on a scale of 10.
b. Client will have a reduction in pain after administration of the prescribed MSC: Client Needs: Safe and Effective Care Environment
analgesic.
c. Client will state an absence of pain 1 hour after administration of the prescribed 12. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
analgesic.
