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Introductory Maternity and Pediatric Nursing 4th Edition Hatfield Test Bank

Introductory Maternity and Pediatric Nursing 4th Edition 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.
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
Nurses are now responsible for various independent functions, including teaching, counseling,
and intervening in nonmedical problems. Interventions initiated by the physician and carried out
by the nurse are called dependent functions. Administrating oral analgesics is a dependent
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
physician through direct orders or protocol.
PTS: 1 DIF: Cognitive Level: Understanding REF: 24
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Safe and Effective Care Environment
3. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth
should be made by the nurse?
a. Everything will be OK.
b. Dont worry about it. It will be over soon.
c. What concerns you most about a cesarean birth?
d. The physician will be in later and you can talk to him.
ANS: C
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,
Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will
be over soon will indicate that the clients feelings are not important. The response, The physician
will be in later and you can talk to him does not allow the client to verbalize her feelings when
she wishes to do that.
PTS: 1 DIF: Cognitive Level: Application REF: 18
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
4. Which action should the nurse take to evaluate the clients learning about performing infant
care?
a. Demonstrate infant care procedures.
b. Allow the client to verbalize the procedure.
c. Routinely assess the infant for cleanliness.
d. Observe the client as she performs the procedure.
ANS: D
The clients correct performance of the procedure under the nurses supervision is the best proof of
her ability. Demonstration is an excellent teaching method, but not an evaluation method. During
verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is
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
used.
PTS: 1 DIF: Cognitive Level: Application REF: 21
OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance
5. A nurse is reviewing teaching and learning principles. Which situation is most conducive to
learning?
a. An auditorium is being used as a classroom for 300 students.
b. A teacher who speaks very little Spanish is teaching a class of Hispanic students.
c. A class is composed of students of various ages and educational backgrounds.
d. An Asian nurse provides nutritional information to a group of pregnant Asian
women.
ANS: D
A clients culture influences the learning process; thus, a situation that is most conducive to
learning is one in which the teacher has knowledge and understanding of the clients cultural
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
the language in which teaching is done determines how much the client learns. Clients for whom
English is not their primary language may not understand idioms, nuances, slang terms, informed
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
to present the information in the best way, the class should be at the same level.
PTS: 1 DIF: Cognitive Level: Application REF: 20
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
6. Which is the step of the nursing process in which the nurse determines the appropriate
interventions for the identified nursing diagnosis?
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: A
The third step in the nursing process involves planning care for problems that were identified
during assessment. The evaluation phase is determining whether the goals have been met. During
the assessment phase, data are collected. The intervention phase is when the plan of care is
carried out.
PTS: 1 DIF: Cognitive Level: Understanding REF: 24
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
7. Which goal is most appropriate for the collaborative problem of wound infection?
a. The client will not exhibit further signs of infection.
b. Maintain the clients fluid intake at 1000 mL/8 hr.
c. The client will have a temperature of 98.6 F within 2 days.
d. Monitor the client to detect therapeutic response to antibiotic therapy.
ANS: D
In a collaborative problem, the goal should be nurse-oriented and reflect the nursing
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.
Monitoring a clients temperature is an independent nursing role.
PTS: 1 DIF: Cognitive Level: Application REF: 18
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
8. Which nursing intervention is correctly written?
a. Force fluids as necessary.
b. Observe interaction with the infant.
c. Encourage turning, coughing, and deep breathing.
d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
ANS: D
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
not detailed and specific. Observing interaction with the infant does not state how often this
procedure should be done.
PTS: 1 DIF: Cognitive Level: Application REF: 25
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
9. The client makes the statement: Im afraid to take the baby home tomorrow. Which response
by the nurse would be the most therapeutic?
a. Youre afraid to take the baby home?
b. Dont you have a mother who can come and help?
c. You should read the literature I gave you before you leave.
d. I was scared when I took my first baby home, but everything worked out.
ANS: A
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
further communication with the client. Telling the client to read the literature before leaving does
not allow the client to express her feelings further. Sharing your feelings about your experience
with a new baby blocks further communication with the client.
PTS: 1 DIF: Cognitive Level: Application REF: 18, 19
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
10. The nurse is writing an expected outcome for the nursing diagnosisacute pain related to
trauma of tissue, secondary to vaginal birth, as evidenced by client stating pain of 8 on a scale of
10. Which is a correctly stated expected outcome for this problem?
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
analgesic.
c. Client will state an absence of pain 1 hour after administration of the prescribed
analgesic.
d. Client will state that pain is a 2 on a scale of 10, 1 hour after the administration of
the prescribed analgesic.
ANS: D
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
reduction in pain after administration of the prescribed analgesic lacks a measurement. Client
stating an absence of pain 1 hour after the administration of prescribed analgesic is unrealistic.
PTS: 1 DIF: Cognitive Level: Application REF: 25
OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity
11. Which nursing diagnosis should the nurse set as a priority for a laboring client?
a. Risk for anxiety related to upcoming birth
b. Risk for imbalanced nutrition related to NPO status
c. Risk for altered family processes related to new addition to the family
d. Risk for injury (maternal) related to altered sensations and positional or physical
changes
ANS: D
The nurse should determine which problem needs immediate attention. Risk for injury is the
problem that has the priority at this time because it is a safety problem. Risk for anxiety,
imbalanced nutrition, and altered family processes are not the priorities at this time.
PTS: 1 DIF: Cognitive Level: Application REF: 24, 25
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe and Effective Care Environment
12. Regarding advanced roles of nursing, which statement is true with regard to clinical practice?
a. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital
setting.
b. Clinical nurse specialists provide primary care to obstetric clients.
c. Neonatal nurse practitioners provide emergency care in the postbirth setting to
high-risk infants.
d. A certified nurse midwife (CNM) is not considered to be an advanced practice
nurse.
ANS: C
Neonatal NPs provide care for the high-risk neonate in the birth room and in the neonatal
intensive care unit, as needed. FNPs do not participate in childbirth care but can take care of
uncomplicated pregnancies and postbirth care outside of the hospital setting. CNSs work in
hospital settings but do not provide primary care services to clients. A CNM is an advanced
practice nurse who receives additional certification in the specific area of midwifery.
PTS: 1 DIF: Cognitive Level: Application REF: 17
OBJ: Nursing Process Step: Evaluation
MSC: Client Needs: Management of Care: Legal Rights and Responsibilities
13. You are taking care of a couple postbirth who are very eager to learn about bathing
techniques that they can use for their newborn. Which teaching technique could the nurse use to
facilitate parents learning about giving a bath to their newborn infant?
a. Provide direct, step-by-step demonstration to each parent separately to foster
individual retention and comprehension.
b. Present information to parents prior to discharge so that the information will be
current.
c. Have each parent bathe the newborn each time the infant comes to the room and
provide commentary after the skill repetition.
d. Demonstrate bathing techniques on the newborn infant with parents in
attendance.
ANS: D
Demonstration of bathing techniques is a form of role modeling that would enhance teaching and
learning outcomes. Presenting the information at the time of discharge will not allow for
identification of concerns and/or evaluation of whether the skill has been acquired. Although it
may be advantageous to have each parent bathe their newborn, this action would not be advised
in terms of time management and safety related to maintenance of core temperature.
PTS: 1 DIF: Cognitive Level: Application REF: 21
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion: Teaching/Learning
14. Which statement is true regarding the shortage of nurses in the United States?
a. There are a larger proportion of younger nurses in the workforce as compared
with older nurses.
b. As a result of decreased RN-to-client ratios, there is a decrease in client mortality
in the clinical setting.
c. Increased needs for baccalaureate nurses are not being met by current enrollment.
d. There are adequate classroom and clinical facilities for training RNs.
ANS: C
According to an Institute of Medicine (IOM) report, by the year 2020, there will only be 50% of
RNs with baccalaureate degrees. The required demand is at 80%. There are a larger proportion of
older nurses in the workforce based on current research by the IOM. Increased RN-to-client
ratios has resulted in decreased client mortality in the clinical setting. There are limitations of
classroom and clinical facilities to train new nurses adequately.
PTS: 1 DIF: Cognitive Level: Application REF: 16
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion: Teaching/Learning
15. A hospital has achieved Magnet status. Which indicators would be consistent with this type
of certification?
a. There is stratification of communication in a directed manner between nursing
staff and administration.
b. There is increased job satisfaction of nurses, with a low staff turnover rate.
c. Physicians are certified in their respective specialty areas.
d. All nurses have baccalaureate degrees and certification in their clinical specialty
area.
ANS: B
Magnet status is a certification offered by the ANCC (American Nurses Credentialing Center) in
which hospitals apply based on designated criteria that consider nurse job satisfaction, staff
patterns, strength, quality of nursing staff, and open communication. It is not based on physician
status. Although the expectation is that at least 80% of the nurses will have baccalaureate
degrees, most hospitals that achieve Magnet status have 50% of RNs at that level. Also,
certification is not required for all nurses at this point. The expectation with Magnet status is that
nurses will continue to expand their knowledge by earning additional degrees and certification.
PTS: 1 DIF: Cognitive Level: Application REF: 17
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion: Teaching/Learning
16. Which of the following indicates a nurses role as a researcher?
a. Reading peer-reviewed journal articles
b. Working as a member of the interdisciplinary team to provide client care
c. Helping client to obtain home care post-discharge from the hospital
d. Delegating tasks to unlicensed personnel to allow for more teaching time with
clients
ANS: A
A nurse in a researcher role should look to improve her or his knowledge base by reading and
reviewing evidence-based practice information as found in peer-reviewed journals. Working as a
member of the interdisciplinary team to provide client care indicates that the nurse is working as
a collaborator. Helping the client to obtain home care post-discharge from the hospital indicates
that the nurse is working as a client advocate. Delegating tasks to unlicensed personnel to allow
for more teaching time with clients indicates that the nurse is working as a manager.
PTS: 1 DIF: Cognitive Level: Application REF: 21
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion: Teaching/Learning
17. A 16-year-old primipara has just completed her first prenatal visit with the health care
provider. The nurse is preparing to teach her about nutrition during pregnancy. What must the
nurse include in the patients teaching plan?
a. Provide her with pictures of dairy products.
b. Ask her, Are you ready to hear this information now?
c. Read directly from the pamphlet prepared for teen mothers.
d. Provide a comfortable and warm setting after she has put on her street clothes.
ANS: D
The nurse must structure teaching for teens in a way that suits them best. For teaching to be most
effective, the physical environment must be comfortable and distractions to learning must be
kept at a minimum. Pictures, videos, and computer-based materials are more effective teaching
tools for younger clients. Patients must have an attitude of readiness and openness for the
teaching to be effective. However, if the environment is not conducive to learning, efforts for
effective teaching will be minimized.
PTS: 1 DIF: Cognitive Level: Application REF: 18
OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance
18. The nurse states to the newly pregnant patient, Tell me how you feel about being pregnant.
Which communication technique is the nurse using with this patient?
a. Clarifying
b. Paraphrasing
c. Reflection
d. Structuring
ANS: A
The nurse is attempting to follow up and check the accuracy of the patients message.
Paraphrasing is restating words other than those used by the patient. Reflection is verbalizing
comprehension of what the patient has said. Structuring takes place when the nurse has set
guidelines or set priorities.
PTS: 1 DIF: Cognitive Level: Understanding REF: 19
OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance
19. The pregnant woman tells the nurse, I think something may be wrong with my pregnancy.
Which statement by the nurse demonstrates therapeutic communication?
a. Most women worry; I felt the same way when I was pregnant.
b. Tell me more about what concerns you about this pregnancy.
c. That is a very common concern, but your pregnancy will turn out just fine.
d. You should focus on taking care of yourself and not worry so much.
ANS: B
Questioning is a therapeutic communication technique in which additional information is elicited
by using open-ended questions. The remaining options are examples of three behaviors that
block communicationinappropriate self-disclosure, providing false reassurance, and giving
advice.
PTS: 1 DIF: Cognitive Level: Analysis REF: 18
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
20. The nurse is formulating a nursing care plan for a postpartum client. Which actions by the
nurse indicate use of critical thinking skills when formulating the care plan? (Select all that
apply).
a. Using a standardized postpartum care plan
b. Determining priorities for each diagnosis written
c. Writing interventions from a nursing diagnosis book
d. Reflecting and suspending judgment when writing the care plan
e. Clustering data during the assessment process according to normal versus
abnormal
ANS: B, D, E
Critical thinking focuses on appraisal of the way the individual thinks, and it emphasizes
reflective skepticism. Determining priorities, reflecting and suspending judgment, and clustering
data are actions that indicate the use of critical thinking. Using a standardized care plan and
writing interventions from a nursing diagnosis book do not show that reflection about the clients
individual care is being done.
Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing
MULTIPLE CHOICE
1. The nurse is teaching a homeless pregnant teenager about prenatal care. Which should the
nurse emphasize in the teaching session?
a. The importance of naming the baby
b. Risk factors associated with pregnancy
c. Information about employment opportunities
d. Eating habits that will provide adequate nutrition
ANS: D
Homeless teens are more likely to have poor eating habits, smoke, and have greater risks for
preterm labor, anemia, and hypertension during pregnancy and to deliver a low-birth-weight
(LBW) infant. Teaching about proper eating habits is the priority at this time. Naming the baby,
risk factors associated with pregnancy, and information about employment are not the highest
priorities to teach at this time.
PTS: 1 DIF: Cognitive Level: Application REF: 35
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. The United States ranks 27th in terms of worldwide infant mortality rates. Which factor has
the greatest impact on decreasing the mortality rate of infants?
a. Providing more womens shelters
b. Ensuring early and adequate prenatal care
c. Resolving all language and cultural differences
d. Enrolling pregnant women in the Medicaid program by their eighth month of
pregnancy
ANS: B
Because preterm infants form the largest category of those needing expensive intensive care,
early pregnancy intervention is essential for decreasing infant mortality. The women in shelters
have the same difficulties in obtaining health care as other poor people, particularly lack of
transportation and inconvenient clinic hours. Language and cultural differences are not infant
mortality issues but must be addressed to improve overall health care. Medicaid provides health
care for poor pregnant women, but the process may take weeks to take effect. The eighth month
is too late to apply and receive benefits for this pregnancy.
PTS: 1 DIF: Cognitive Level: Understanding REF: 35
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. Which statement is true regarding the quality assurance or incident report?
a. Reports are a permanent part of the patients chart.
b. The report assures the legal department that there is no problem.
c. The nurses notes should contain this statement: Incident report filed and copy
placed in chart.
d. This report is a form of documentation of an event that may result in legal action.
ANS: D
Documentation on the chart should include all factual information regarding the clients condition
that would be recorded in any situation. The nurse completes an incident report when something
occurs that might result in a legal action against the clinic or hospital. Incident reports are not
part of the patients chart. The report is a warning to the legal department to be prepared for a
potential legal action. Incident reports are not mentioned in the nurses notes.
PTS: 1 DIF: Cognitive Level: Analysis REF: 39
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe and Effective Care Environment
4. The nurse is planning a teaching session for staff on ethical theories. Which situation best
reflects the deontologic theory?
a. Approving a physician-assisted suicide
b. Supporting the transplantation of fetal tissue and organs
c. Using experimental medications for the treatment of AIDS
d. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
ANS: D
In the deontologic theory, life must be maintained at all costs, regardless of quality of life.
Approving a physician-assisted suicide, supporting the transplantation of fetal tissue and organs,
and using experimental medications for the treatment of AIDS are examples of a utilitarian
model.
PTS: 1 DIF: Cognitive Level: Application REF: 29
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
5. Which step of the nursing process is being used when the nurse decides whether an ethical
dilemma exists?
a. Analysis
b. Planning
c. Evaluation
d. Assessment
ANS: A
When a nurse uses the collected data to determine whether an ethical dilemma exists, the data are
being analyzed. Planning is done after the data have been analyzed. Evaluation occurs once the
outcome has been achieved. Assessment is the data collection phase.
PTS: 1 DIF: Cognitive Level: Understanding REF: 30
OBJ: Nursing Process Step: Evaluation
MSC: Client Needs: Safe and Effective Care Environment: Coordinated Care
6. The nurse is interviewing a 6-week pregnant client. The client asks the nurse, Why is elective
abortion considered an ethical issue? Which is the best response that the nurse should make?
a. Abortion requires third-party consent.
b. The U.S. Supreme Court ruled that life begins at conception.
c. Abortion law is unclear about a womans constitutional rights.
d. There is a conflict between the rights of the woman and the rights of the fetus.
ANS: D
Elective abortion is an ethical dilemma because two opposing courses of action are available.
Abortion does not require third-party consent. The Supreme Court has not ruled on when life
begins. Abortion laws are clear concerning a womens constitutional rights.
PTS: 1 DIF: Cognitive Level: Application REF: 31
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe and Effective Care Environment
7. At the present time, surrogate parenting is governed by which of the following?
a. State law
b. Federal law
c. Individual court decision
d. Protective child services
ANS: C
Each surrogacy case is decided individually in a court of law. Surrogacy is not governed by state
law. Surrogacy is not governed by federal law. Protective child services does not make decisions
about surrogacy.
PTS: 1 DIF: Cognitive Level: Understanding REF: 33
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. Which client will most likely seek prenatal care?
a. Janice, 15 years old, tells her friends, I dont believe I am pregnant.
b. Carol, 28 years old, is in her second pregnancy and abuses drugs and alcohol.
c. Margaret, 20 years old, is in her first pregnancy and has access to a free prenatal
clinic.
d. Glenda, 30 years old, is in her fifth pregnancy and delivered her last infant at
home with the help of her mother and sister.
ANS: C
The client who acknowledges the pregnancy early, has access to health care, and has no reason to
avoid health care is most likely to seek prenatal care. Being in denial about the pregnancy will
prevent a client from seeking health care. Substance abusers are less likely to seek health care.
Some women see pregnancy and birth as a natural occurrence and do not seek health care.
PTS: 1 DIF: Cognitive Level: Understanding REF: 35
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance
9. A medical surgical nurse is asked to float to a womens health unit to care for clients who are
scheduled for therapeutic abortions. The nurse refuses to accept this assignment and expresses
her personal beliefs as being incongruent with this medical practice. The nursing supervisor
states that the unit is short-staffed and that they could really use her expertise because it just
involves taking care of clients who have undergone a surgical procedure. In consideration of
legal and ethical practices, can the nursing supervisor enforce this assignment?
a. The staff nurse has the responsibility of accepting any assignment that is made
while working for a health care unit, so the nursing supervisor is within his or her
rights to enforce this assignment.
b. Because the unit is short-staffed, the staff nurse should accept the assignment to
provide care by benefit of her or his experience to clients who need care.
c. The staff nurse has expressed a legitimate concern based on his or her feelings;
the nursing supervisor does not have the authority to enforce this assignment.
d. The nursing supervisor should emphasize that this assignment requires care of a
surgical client for which the staff nurse is adequately trained and should therefore
enforce the assignment.
ANS: C
The Nurse Practice Act allows nurses to refuse assignments that involve practices that they have
expressed as being opposed to their religious, cultural, ethical, and/or moral values. Although the
nursing supervisor has a right to arrange assignments, the supervisor, if made aware of a
potential bias or limitation, must act accordingly and accept the nurses position. This should be
upheld regardless of staffing limitations and independent of persuasive efforts to make the nurse
feel guilty for her or his stated beliefs.
PTS: 1 DIF: Cognitive Level: Analysis REF: 31
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Ethical Practice/Assignment, Delegation and
Supervision
10. With regard to an obstetric litigation case, a nurse working in labor and birth is found to be
negligent. Which intervention performed by the nurse indicates that a breach of duty has
occurred?
a. The nurse did not document fetal heart tones (FHR) during the second stage of
labor.
b. The client was only provided ice chips during the labor period, which lasted 8
hours.
c. The nurse allowed the client to use the bathroom rather than a bedpan during the
first stage of labor.
d. The nurse asked family members to leave the room when she prepared to do a
pelvic exam on the client.
ANS: A
A breach of duty is indicated by a nurse (or health care provider) failing to provide treatment
relative to the standard of care. In this case, documentation of FHR during the second stage of
labor is a standard of care. Providing ice chips to laboring clients is within the standard of care.
The time period of 8 hours is not excessive. A client without any risk factors can use the
bathroom and be ambulatory during the first stage of labor. Asking family members to leave
during a vaginal exam helps maintain client privacy.
PTS: 1 DIF: Cognitive Level: Analysis REF: 37
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities
11. A nurse is working with a labor client who is in preterm labor and is designated as a high-risk
client. The client is very apprehensive and asks the nurse, Is everything going to be all right? The
nurse tells the client, Everything will be okay. Following birth via an emergency cesarean
section, the newborn undergoes resuscitation and does not survive. The client is distraught over
the outcome and blames the nurse for telling her that everything would be okay. Which ethical
principle did the nurse violate?
a. Autonomy
b. Fidelity
c. Beneficence
d. Accountability
ANS: B
In this type of situation, the nurse (and/or health care provider) cannot make statements
(promises) that cannot be kept. Telling the client that everything will be okay is not based on the
accuracy of medical diagnosis and should not be conveyed to the client. The other ethical
principles of autonomy (self-determination), beneficence (greatest good), and accountability
(accepting responsibility) do not apply.
PTS: 1 DIF: Cognitive Level: Analysis REF: 30
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities
12. A nurse is working in the area of labor and birth. Her assignment is to take care of a gravida
1 para 0 who presents in early labor at term. Vaginal exam reflects the following: 2 cm, cervix
posterior, 1 station, and vertex with membranes intact. The client asks the nurse if she can break
her water so that her labor can go faster? The nurses response, based on the ethical principle of
nonmaleficence, is which of the following?
a. Tell the client that she will have to wait until she has progressed further on the
vaginal exam and then she will perform an amniotomy.
b. Have the client write down her request and then call the physician for an order to
implement the amniotomy.
c. Instruct the client that only a physician or certified midwife can perform this
procedure.
d. Give the client an enema to stimulate labor.
ANS: C
The ethical principle of nonmaleficence conveys the concept that one should avoid risk taking or
harm to others. The procedure of amniotomy is performed by a physician and/or certified nurse
midwife. It is not in the scope of practice of a RN, so option C validates that the nurse is
upholding this ethical principle. Options A and B are not within the scope of practice. The use of
an enema as a labor stimulant is no longer considered to be part of labor and birth practices.
PTS: 1 DIF: Cognitive Level: Analysis REF: 30
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities
13. A nurse working in a labor and birth unit is asked to take care of two high-risk clients in the
labor and birth suite: a 34 weeks gestation 28-year-old gravida 3, para 2 in preterm labor and a
40-year-old gravida 1, para 0 who is severely preeclamptic. The nurse refuses this assignment
telling the charge nurse that based on individual client acuity, each client should have one-onone
care. Which ethical principle is the nurse advocating?
a. Accountability
b. Beneficence
c. Justice
d. Fidelity
ANS: B
In this situation, the clients are each exhibiting significant high-risk conditions and should
receive individual nursing care. The nurse is advocating the principle of beneficence in that she
is trying to do the greatest good or the least harm to improve client outcomes. The other ethical
principles do not apply in this situation.
PTS: 1 DIF: Cognitive Level: Analysis REF: 30
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities
14. A charge nurse is working on a postpartum unit and discovers that one of the clients did not
receive AM care during her shift assessment. The charge nurse questions the nurse assigned to
provide care and finds out that the nurse thought that the client should just do it by herself
because she will have to do this at home. On further questioning of the nurse, it is determined
that the rest of her assigned clients were provided AM care. The assigned nurse has violated
which ethical principle?
a. Justice
b. Truth
c. Confidentiality
d. Autonomy
ANS: A
The ethical principle of justice indicates that all clients should be treated equally and fairly. In
this case, the charge nurse ascertained that the AM care was not equally applied to all the nurses
assigned clients. The other ethical principles do not apply to this situation.
PTS: 1 DIF: Cognitive Level: Analysis REF: 30
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities
15. A nurse is entering information on the clients electronic health record (EHR) and is called to
assist in an emergency situation with regard to another client in the labor and birth suite. The
nurse rushes to the scene to assist but leaves the chart open on the computer screen. The
emergent client situation is resolved satisfactorily, and the nurse comes back to the computer
entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with
the nurse and tells her that she is concerned with what happened today on the unit because there
was a breach in confidentiality. Which response by the nurse indicates that she understands the
nurse managers concerns?
a. The nurse acknowledges that she should have made sure that her client was safe
before assisting with the emergency.
b. The nurse states that she should have logged out of the EHR prior to attending to
the emergency.
c. The nurse indicates that the unit was understaffed.
d. The nurse indicates that the she changed her password following the clinical
emergency to maintain confidentiality.
ANS: B
With the use of electronic health records, it is necessary to take all steps to maintain
confidentiality and limit access to nonhealth care personnel. In an emergent care situation, the
nurse should have logged out of the system to maintain confidentiality. Although it is important
to make sure that ones client is safe, there is no information here to suggest that there were any
safety issues applicable to her assigned client. The staffing of the unit should not affect
confidentiality. Changing the password for logging in to a system is an option for clinical
practice but does not affect the situation as described.
PTS: 1 DIF: Cognitive Level: Analysis REF: 30
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe Effective Care: Legal Rights and Responsibilities
16. Which of the following statements is true regarding late preterm infants?
a. These infants are born before 32 weeks gestation and thus are at higher risk than
LBW infants.
b. These infants do better than LBW infants because their weight provides added
protection against physiologic stressors.
c. Care of these infants has led to increased health care costs compared with LBW
infants.
d. These infants suffer fewer respiratory problems than LBW infants.
ANS: C
Late preterm infants are born between 34 and 36 weeks and present with more complications
than LBW infants, according to evidence-based practice. The added weight does not provide
protection, and these infants are more likely to experience respiratory distress.
PTS: 1 DIF: Cognitive Level: Application REF: 36
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Adaptation
17. A nurse is admitting a client to the labor and birth unit in early labor who was sent to the
facility following her checkup with her health care provider in the office. The client is a gravida
1, para 0, and is at term. No health issues are discerned from the initial assessment, and the nurse
prepares to initiate physician orders based on standard procedures. Which action is warranted by
the nurse manager in response to this situation?
a. No action is indicated because the nurse is acting within the scope of practice.
b. The nurse manager should intervene and ask the nurse to clarify admission orders
directly with the physician.
c. The nurse manager should review standard procedures with the nurse to validate
that orders are being carried out accurately.
d. The nurse manger should review the admission procedure with the nurse.
ANS: A
Standard procedures are often used in labor and birth settings because they are based on
physician-directed orders that apply to general admissions. The nurse is acting appropriately
because the client was sent directly to the unit by the health care provider. The nurse manager