FOUNDATIONS OF MATERNAL-
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1) Clinical Judgment and the Nursing Process
Reference: Part 1 — Clinical Judgment and the Nursing Process
— Prioritizing an Abnormal Postpartum Assessment
A postpartum client is 45 minutes after birth. The nurse finds a
saturated perineal pad in 8 minutes, a boggy uterus above the
umbilicus, and the client says she feels lightheaded. What
should the LPN do first?
A. Encourage the client to empty her bladder
B. Notify the RN immediately and stay with the client
,C. Apply a heating pad to the abdomen
D. Reassess the lochia in 30 minutes
Correct Answer: B
Rationale — Correct Answer:
Heavy bleeding with a boggy uterus suggests postpartum
hemorrhage. The LPN should act immediately by getting the RN
and remaining with the client while help arrives. This is an
urgent change in status that requires rapid escalation.
Rationale — Incorrect Options:
A. Emptying the bladder can help uterine tone, but it is not the
first action in suspected hemorrhage.
C. Heat is not an appropriate response to active postpartum
bleeding.
D. Waiting delays treatment and is unsafe.
Teaching Point: Report heavy bleeding and a boggy uterus right
away.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
Reference: Part 1 — Clinical Judgment and the Nursing Process
— Recognizing a High-Priority Maternal Symptom
,A client at 34 weeks’ gestation comes to the clinic reporting a
severe headache and “seeing spots.” Her blood pressure is
156/100 mm Hg. What should the LPN do first?
A. Tell the client to rest and return next week
B. Report the finding to the RN or provider immediately
C. Reassure the client that swelling is common in pregnancy
D. Ask the client to drink more water and eat a snack
Correct Answer: B
Rationale — Correct Answer:
Severe headache, visual changes, and elevated blood pressure
are warning signs of possible preeclampsia. The LPN must
report these findings immediately for further evaluation. This is
a priority safety issue, not a routine pregnancy complaint.
Rationale — Incorrect Options:
A. Delaying care is unsafe when preeclampsia is possible.
C. Swelling may be common, but the headache and visual
changes are concerning.
D. Fluids and food do not address a potentially dangerous
hypertensive disorder.
Teaching Point: Headache plus visual changes in pregnancy
must be reported immediately.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
, Reference: Part 1 — Clinical Judgment and the Nursing Process
— Recognizing Imminent Birth
A laboring client is 9 cm dilated and says, “I need to push now.”
She is grunting with contractions and reports strong rectal
pressure. What is the best LPN action?
A. Encourage the client to push with every contraction without
delay
B. Leave to get supplies and return later
C. Stay with the client, notify the RN, and prepare for birth
D. Offer ice chips and tell the client this feeling is normal
Correct Answer: C
Rationale — Correct Answer:
Grunting and rectal pressure at 9 cm suggest transition and
possible imminent birth. The LPN should stay with the client,
notify the RN, and prepare the environment for delivery. This is
a time-sensitive change that needs immediate nursing support.
Rationale — Incorrect Options:
A. Pushing before full dilation can increase risk of injury.
B. Leaving the client is unsafe when birth may be near.
D. Ice chips may be helpful, but this does not address the
urgent situation.
Teaching Point: Rectal pressure and bearing down can signal
imminent birth.
NEWBORN AND WOMEN'S
HEALTH NURSING
8TH EDITION
• AUTHOR(S)SHARON MURRAY
TEST BANK
1) Clinical Judgment and the Nursing Process
Reference: Part 1 — Clinical Judgment and the Nursing Process
— Prioritizing an Abnormal Postpartum Assessment
A postpartum client is 45 minutes after birth. The nurse finds a
saturated perineal pad in 8 minutes, a boggy uterus above the
umbilicus, and the client says she feels lightheaded. What
should the LPN do first?
A. Encourage the client to empty her bladder
B. Notify the RN immediately and stay with the client
,C. Apply a heating pad to the abdomen
D. Reassess the lochia in 30 minutes
Correct Answer: B
Rationale — Correct Answer:
Heavy bleeding with a boggy uterus suggests postpartum
hemorrhage. The LPN should act immediately by getting the RN
and remaining with the client while help arrives. This is an
urgent change in status that requires rapid escalation.
Rationale — Incorrect Options:
A. Emptying the bladder can help uterine tone, but it is not the
first action in suspected hemorrhage.
C. Heat is not an appropriate response to active postpartum
bleeding.
D. Waiting delays treatment and is unsafe.
Teaching Point: Report heavy bleeding and a boggy uterus right
away.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
Reference: Part 1 — Clinical Judgment and the Nursing Process
— Recognizing a High-Priority Maternal Symptom
,A client at 34 weeks’ gestation comes to the clinic reporting a
severe headache and “seeing spots.” Her blood pressure is
156/100 mm Hg. What should the LPN do first?
A. Tell the client to rest and return next week
B. Report the finding to the RN or provider immediately
C. Reassure the client that swelling is common in pregnancy
D. Ask the client to drink more water and eat a snack
Correct Answer: B
Rationale — Correct Answer:
Severe headache, visual changes, and elevated blood pressure
are warning signs of possible preeclampsia. The LPN must
report these findings immediately for further evaluation. This is
a priority safety issue, not a routine pregnancy complaint.
Rationale — Incorrect Options:
A. Delaying care is unsafe when preeclampsia is possible.
C. Swelling may be common, but the headache and visual
changes are concerning.
D. Fluids and food do not address a potentially dangerous
hypertensive disorder.
Teaching Point: Headache plus visual changes in pregnancy
must be reported immediately.
Citation: Murray, S. (2024). Foundations of Maternal-Newborn
and Women’s Health Nursing (8th ed.). Part 1: Clinical Judgment
and the Nursing Process.
, Reference: Part 1 — Clinical Judgment and the Nursing Process
— Recognizing Imminent Birth
A laboring client is 9 cm dilated and says, “I need to push now.”
She is grunting with contractions and reports strong rectal
pressure. What is the best LPN action?
A. Encourage the client to push with every contraction without
delay
B. Leave to get supplies and return later
C. Stay with the client, notify the RN, and prepare for birth
D. Offer ice chips and tell the client this feeling is normal
Correct Answer: C
Rationale — Correct Answer:
Grunting and rectal pressure at 9 cm suggest transition and
possible imminent birth. The LPN should stay with the client,
notify the RN, and prepare the environment for delivery. This is
a time-sensitive change that needs immediate nursing support.
Rationale — Incorrect Options:
A. Pushing before full dilation can increase risk of injury.
B. Leaving the client is unsafe when birth may be near.
D. Ice chips may be helpful, but this does not address the
urgent situation.
Teaching Point: Rectal pressure and bearing down can signal
imminent birth.
