FOUNDATIONS OF MATERNAL-
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1. Reference: Part 1 — Foundations for Nursing Care of
Childbearing Families — Clinical Judgment and the
Nursing Process
Stem: A postpartum client reports feeling “dizzy and weak”
while standing for the first time after birth. The nurse notes a
saturated perineal pad and a pulse of 112/min. The practical
nurse is assisting with care on the postpartum unit. What
should the nurse do first?
,Options:
A. Encourage the client to walk to improve circulation
B. Assess the amount of bleeding and notify the RN
C. Teach the client that dizziness is expected after delivery
D. Offer a warm blanket and recheck vital signs in 1 hour
Correct Answer: B
Rationale — Correct Answer: Dizziness with tachycardia and a
saturated pad may indicate postpartum blood loss. The LPN
should recognize this as an abnormal finding, assess the
amount of bleeding as part of immediate observation, and
report promptly to the RN. Early recognition supports maternal
safety and rapid intervention.
Rationale — Incorrect Options:
A. Ambulation is not the first action when possible hemorrhage
is suspected. Activity may worsen the client’s instability.
C. Dizziness is not an expected finding when accompanied by
tachycardia and heavy bleeding. This delays needed care.
D. Delaying reassessment could miss worsening blood loss. This
is not appropriate when a priority problem is present.
Teaching Point: Dizziness plus heavy lochia may signal
postpartum hemorrhage.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
, 2. Reference: Part 1 — Foundations for Nursing Care of
Childbearing Families — Clinical Judgment and the
Nursing Process
Stem: A laboring client says, “My contractions are getting
stronger, and I feel pressure in my rectum.” The external fetal
monitor shows contractions every 2 minutes. The nurse notes
the client is moaning and cannot talk through contractions.
What is the best nursing interpretation?
Options:
A. The client is likely in early labor and should rest
B. The client may be in the transition phase and needs close
observation
C. The client is having false labor and should be reassured
D. The client is overreacting and should be coached to breathe
slower
Correct Answer: B
Rationale — Correct Answer: Rectal pressure, strong frequent
contractions, and inability to talk through contractions are
consistent with transition phase labor. The LPN should
recognize this as advanced labor and increase observation,
comfort measures, and prompt reporting if needed. This
supports safe, timely care.
Rationale — Incorrect Options:
A. Early labor usually has milder contractions and less intense
pressure.
, C. False labor contractions are irregular and do not progress as
described.
D. The symptoms are physiologic labor findings, not
overreaction. This response is disrespectful and unsafe.
Teaching Point: Rectal pressure and strong frequent
contractions suggest advanced labor.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
3. Reference: Part 1 — Foundations for Nursing Care of
Childbearing Families — Safety and Quality Within
Women’s Health
Stem: A new mother asks the practical nurse to hand her
newborn to a visitor who just arrived. The infant is in the
bassinet with matching identification bands in place. The visitor
says, “I am the baby’s aunt, so it is fine.” What should the nurse
do first?
Options:
A. Place the infant in the visitor’s arms after verifying the last
name
B. Ask for the visitor’s photo identification before releasing the
infant
C. Remove the infant’s bands so they do not irritate the skin
D. Tell the mother to take the infant to the nursery herself
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1. Reference: Part 1 — Foundations for Nursing Care of
Childbearing Families — Clinical Judgment and the
Nursing Process
Stem: A postpartum client reports feeling “dizzy and weak”
while standing for the first time after birth. The nurse notes a
saturated perineal pad and a pulse of 112/min. The practical
nurse is assisting with care on the postpartum unit. What
should the nurse do first?
,Options:
A. Encourage the client to walk to improve circulation
B. Assess the amount of bleeding and notify the RN
C. Teach the client that dizziness is expected after delivery
D. Offer a warm blanket and recheck vital signs in 1 hour
Correct Answer: B
Rationale — Correct Answer: Dizziness with tachycardia and a
saturated pad may indicate postpartum blood loss. The LPN
should recognize this as an abnormal finding, assess the
amount of bleeding as part of immediate observation, and
report promptly to the RN. Early recognition supports maternal
safety and rapid intervention.
Rationale — Incorrect Options:
A. Ambulation is not the first action when possible hemorrhage
is suspected. Activity may worsen the client’s instability.
C. Dizziness is not an expected finding when accompanied by
tachycardia and heavy bleeding. This delays needed care.
D. Delaying reassessment could miss worsening blood loss. This
is not appropriate when a priority problem is present.
Teaching Point: Dizziness plus heavy lochia may signal
postpartum hemorrhage.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
, 2. Reference: Part 1 — Foundations for Nursing Care of
Childbearing Families — Clinical Judgment and the
Nursing Process
Stem: A laboring client says, “My contractions are getting
stronger, and I feel pressure in my rectum.” The external fetal
monitor shows contractions every 2 minutes. The nurse notes
the client is moaning and cannot talk through contractions.
What is the best nursing interpretation?
Options:
A. The client is likely in early labor and should rest
B. The client may be in the transition phase and needs close
observation
C. The client is having false labor and should be reassured
D. The client is overreacting and should be coached to breathe
slower
Correct Answer: B
Rationale — Correct Answer: Rectal pressure, strong frequent
contractions, and inability to talk through contractions are
consistent with transition phase labor. The LPN should
recognize this as advanced labor and increase observation,
comfort measures, and prompt reporting if needed. This
supports safe, timely care.
Rationale — Incorrect Options:
A. Early labor usually has milder contractions and less intense
pressure.
, C. False labor contractions are irregular and do not progress as
described.
D. The symptoms are physiologic labor findings, not
overreaction. This response is disrespectful and unsafe.
Teaching Point: Rectal pressure and strong frequent
contractions suggest advanced labor.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
3. Reference: Part 1 — Foundations for Nursing Care of
Childbearing Families — Safety and Quality Within
Women’s Health
Stem: A new mother asks the practical nurse to hand her
newborn to a visitor who just arrived. The infant is in the
bassinet with matching identification bands in place. The visitor
says, “I am the baby’s aunt, so it is fine.” What should the nurse
do first?
Options:
A. Place the infant in the visitor’s arms after verifying the last
name
B. Ask for the visitor’s photo identification before releasing the
infant
C. Remove the infant’s bands so they do not irritate the skin
D. Tell the mother to take the infant to the nursery herself
