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
Stem:
A laboring client at 39 weeks reports a sudden severe headache
and “flashing lights” in both eyes. The blood pressure is
164/104 mm Hg, and the client appears anxious. The LPN is
assisting with care in triage.
Options:
A. Recheck the blood pressure in 1 hour
B. Encourage the client to walk to improve comfort
,C. Notify the RN immediately and keep the client on bed rest
D. Offer oral fluids and reassess after the client rests
Correct Answer: C
Rationales:
C. Correct. Severe headache, visual changes, and markedly
elevated blood pressure are warning signs of a hypertensive
disorder of pregnancy. The LPN should report the findings
immediately and support safety by limiting activity until the
RN/provider evaluates the client.
A. Incorrect. Delaying reassessment can postpone urgent
treatment. These findings require immediate escalation, not
observation.
B. Incorrect. Ambulation is not appropriate when preeclampsia
is suspected and the client is symptomatic. Safety takes priority.
D. Incorrect. Oral fluids and rest do not address the urgent
maternal risk. The abnormal findings must be reported right
away.
Teaching Point:
Severe headache and vision changes in pregnancy require
immediate reporting.
Citation:
Murray, S. (n.d.). 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
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem:
A postpartum client says, “I feel dizzy when I sit up.” The LPN
notes a blood pressure of 88/54 mm Hg and a pulse of 116/min.
The client is 6 hours after delivery and has a moderate amount
of lochia rubra.
Options:
A. Document the findings as expected after delivery
B. Assist the client to lie down and notify the RN promptly
C. Encourage the client to ambulate to improve circulation
D. Reassess the client after the next scheduled round
Correct Answer: B
Rationales:
B. Correct. Dizziness with hypotension and tachycardia may
indicate blood loss or volume depletion. The LPN should reduce
fall risk, keep the client safe, and promptly report the abnormal
findings.
A. Incorrect. These findings are not expected postpartum and
may signal a complication.
C. Incorrect. Ambulation increases fall risk and may worsen
symptoms. Safety is the priority.
D. Incorrect. Waiting can delay treatment for a potentially
serious condition.
, Teaching Point:
Dizziness with low blood pressure after birth is abnormal and
must be reported.
Citation:
Murray, S. (n.d.). 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
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem:
A postpartum client asks why the nurse keeps checking the
fundus, lochia, and bladder status. The LPN plans to give a brief
explanation during care.
Options:
A. “These checks help us identify bleeding and support normal
recovery.”
B. “These checks are done only if the client requests them.”
C. “These checks are mainly for charting and legal purposes.”
D. “These checks are unnecessary if the client feels well.”
Correct Answer: A
Rationales:
A. Correct. Fundal tone, lochia, and bladder status are key
indicators of postpartum recovery and possible bleeding. This
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
Stem:
A laboring client at 39 weeks reports a sudden severe headache
and “flashing lights” in both eyes. The blood pressure is
164/104 mm Hg, and the client appears anxious. The LPN is
assisting with care in triage.
Options:
A. Recheck the blood pressure in 1 hour
B. Encourage the client to walk to improve comfort
,C. Notify the RN immediately and keep the client on bed rest
D. Offer oral fluids and reassess after the client rests
Correct Answer: C
Rationales:
C. Correct. Severe headache, visual changes, and markedly
elevated blood pressure are warning signs of a hypertensive
disorder of pregnancy. The LPN should report the findings
immediately and support safety by limiting activity until the
RN/provider evaluates the client.
A. Incorrect. Delaying reassessment can postpone urgent
treatment. These findings require immediate escalation, not
observation.
B. Incorrect. Ambulation is not appropriate when preeclampsia
is suspected and the client is symptomatic. Safety takes priority.
D. Incorrect. Oral fluids and rest do not address the urgent
maternal risk. The abnormal findings must be reported right
away.
Teaching Point:
Severe headache and vision changes in pregnancy require
immediate reporting.
Citation:
Murray, S. (n.d.). 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
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem:
A postpartum client says, “I feel dizzy when I sit up.” The LPN
notes a blood pressure of 88/54 mm Hg and a pulse of 116/min.
The client is 6 hours after delivery and has a moderate amount
of lochia rubra.
Options:
A. Document the findings as expected after delivery
B. Assist the client to lie down and notify the RN promptly
C. Encourage the client to ambulate to improve circulation
D. Reassess the client after the next scheduled round
Correct Answer: B
Rationales:
B. Correct. Dizziness with hypotension and tachycardia may
indicate blood loss or volume depletion. The LPN should reduce
fall risk, keep the client safe, and promptly report the abnormal
findings.
A. Incorrect. These findings are not expected postpartum and
may signal a complication.
C. Incorrect. Ambulation increases fall risk and may worsen
symptoms. Safety is the priority.
D. Incorrect. Waiting can delay treatment for a potentially
serious condition.
, Teaching Point:
Dizziness with low blood pressure after birth is abnormal and
must be reported.
Citation:
Murray, S. (n.d.). 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
Reference: Part 1 — Clinical Judgment and the Nursing Process
Stem:
A postpartum client asks why the nurse keeps checking the
fundus, lochia, and bladder status. The LPN plans to give a brief
explanation during care.
Options:
A. “These checks help us identify bleeding and support normal
recovery.”
B. “These checks are done only if the client requests them.”
C. “These checks are mainly for charting and legal purposes.”
D. “These checks are unnecessary if the client feels well.”
Correct Answer: A
Rationales:
A. Correct. Fundal tone, lochia, and bladder status are key
indicators of postpartum recovery and possible bleeding. This
