TEST BANK FOR n n
Murray Foundations of Maternal-Newborn and Women's Health Nursing, 8th
n n n n n n n n
Edition
n
Chapter 01: n
MULTIPLE nCHOICE
1. A nnurse neducator nis nteaching na ngroup nof nnursing nstudents nabout nthe nhistory nof
family-centered nmaternity ncare. nWhich nstatement nshould nthe nnurse ninclude nin nthe nteaching
nsession?
a. The nSheppard-Towner nAct nof n1921 npromoted nfamily-centered ncare.
b. Changes nin npharmacologic nmanagement nof nlabor nprompted nfamily-centered ncare.
c. Demands nby nphysicians nfor nfamily ninvolvement nin nchildbirth nincreased nthe
npractice
of nfamily-centered ncare.
d. Parental nrequests nthat ninfants nbe nallowed nto nremain nwith nthem nrather nthan nin na
nursery ninitiated nthe npractice nof nfamily-centered ncare.
ANS: n D
As nresearch nbegan nto nidentify nthe nbenefits nof nearly, nextended nparent–infant ncontact,
nparents nbegan nto ninsist nthat nthe ninfant nremain nwith nthem. nThis ngradually ndeveloped ninto
nthe npractice nof nrooming-in nand nfinally nto nfamily-centered nmaternity ncare. nThe nSheppard-
Towner nAct nprovided nfunds nfor nstate-managed nprograms nfor nmothers nand nchildren nbut
ndid nnot npromote nfamily-centered ncare. nThe nchanges nin npharmacologic nmanagement nof
nlabor nwere nnot na nfactor nin nfamily-centered nmaternity ncare. nFamily-centered ncare nwas na
nrequest nby nparents, nnot nphysicians.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nHealth nPromotion nand nMaintenance
2. Expectant nparents nask na nprenatal nnurse neducator, n―Which nsetting nfor nchildbirth nlimits nthe
amount nof nparent–infant ninteraction?‖ nWhich nanswer nshould nthe nnurse nprovide nfor
n
these nparents nin norder nto nassist nthem nin nchoosing nan nappropriate nbirth nsetting?
n
a. Birth ncenter
b. Home nbirth
c. Traditional nhospital nbirth
d. Labor, nbirth, nand nrecovery nroom
ANS: n C
In nthe ntraditional nhospital nsetting, nthe nmother nmay nsee nthe ninfant nfor nonly nshort nfeeding
nperiods, nand nthe ninfant nis ncared nfor nin na nseparate nnursery. nBirth ncenters nare nset nup nto
nallow nan nincrease nin nparent–infant ncontact. nHome nbirths nallow nthe ngreatest namount nof
parent–infant ncontact. nThe nlabor, nbirth, nrecovery, nand npostpartum nroom nsetting nallows nfor
nincreased nparent–infant ncontact.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nHealth nPromotion nand nMaintenance
,3. Which nstatement nbest ndescribes nthe nadvantage nof na nlabor, nbirth, nrecovery, nand
postpartum n(LDRP) nroom?
n
a. The nfamily nis nin na nfamiliar nenvironment.
b. They nare nless nexpensive nthan ntraditional nhospital nrooms.
c. The ninfant nis nremoved nto nthe nnursery nto nallow nthe nmother nto nrest.
d. The nwoman‘s nsupport nsystem nis nencouraged nto nstay nuntil
ndischarge.
ANS: n D
Sleeping nequipment nis nprovided nin na nprivate nroom. nA nhospital nsetting nis nnever na nfamiliar
nenvironment nto nnew nparents. nAn nLDRP nroom nis nnot nless nexpensive nthan na ntraditional
nhospital nroom. nThe nbaby nremains nwith nthe nmother nat nall ntimes nand nis nnot nremoved nto nthe
nnursery nfor nroutine ncare nor ntesting. nThe nfather nor nother ndesignated nmembers nof nthe
nmother‘s nsupport nsystem nare nencouraged nto nstay nat nall ntimes.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nAssessment nMSC: n Patient nNeeds: nHealth nPromotion nand nMaintenance
4. Which nnursing nintervention nis nan nindependent nfunction nof nthe nprofessional nnurse?
a. Administering noral nanalgesics
b. Requesting ndiagnostic nstudies
c. Teaching nthe npatient nperineal ncare
d. Providing nwound ncare nto na nsurgical
n incision
ANS: n C
Nurses nare nnow nresponsible nfor nvarious nindependent nfunctions, nincluding nteaching,
ncounseling, nand nintervening nin nnonmedical nproblems. nInterventions ninitiated nby nthe
nphysician nand ncarried nout nby nthe nnurse nare ncalled ndependent nfunctions. nAdministrating
noral nanalgesics nis na ndependent nfunction; nit nis ninitiated nby na nphysician nand ncarried nout nby na
nnurse. nRequesting ndiagnostic nstudies nis na ndependent nfunction. nProviding nwound ncare nis na
ndependent nfunction; nhowever, nthe nphysician nprescribes nthe ntype nof nwound ncare nthrough
ndirect norders nor nprotocol.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nAssessment nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
5. Which nresponse nbynthe nnurse nis nthe nmost ntherapeutic nwhen nthe npatient nstates, n―I‘m nso
afraid nto nhave na ncesarean nbirth‖?
n
a. ―Everything nwill nbe nOK.‖
b. ―Don‘t nworrynabout nit. nIt nwill nbe nover nsoon.‖
c. ―What nconcerns nyou nmost nabout na ncesarean nbirth?‖
d. ―The nphysician nwill nbe nin nlater nand nyou ncan ntalk nto nhim.‖
ANS: n C
The nresponse, n―What nconcerns nyou nmost nabout na ncesarean nbirth‖ nfocuses non nwhat nthe
npatient nis nsaying nand nasks nfor nclarification, nwhich nis nthe nmost ntherapeutic nresponse. nThe
nresponse, n―Everything nwill nbe nok‖ nis nbelittling nthe npatient‘s nfeelings. nThe nresponse,
n―Don‘t nworry nabout nit. nIt nwill nbe nover nsoon‖ nwill nindicate nthat nthe npatient‘s nfeelings nare
nnot nimportant. nThe nresponse, n―The nphysician nwill nbe nin nlater nand nyou ncan ntalk nto nhim‖
ndoes nnot nallow nthe npatient nto nverbalize nher nfeelings nwhen nshe nwishes nto ndo nthat.
DIF: Cognitive nLevel: nApplication OBJ: n n Nursing nProcess nStep: nImplementation
, MSC: n Patient nNeeds: nPsychosocial nIntegrity
6. In nwhich nstep nof nthe nnursing nprocess ndoes nthe nnurse ndetermine nthe nappropriate
interventions nfor nthe nidentified nnursing ndiagnosis?
n
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: n A
The nthird nstep nin nthe nnursing nprocess ninvolves nplanning ncare nfor nproblems nthat nwere
nidentified nduring nassessment. nThe nevaluation nphase nis ndetermining nwhether nthe ngoals
nhave nbeen nmet. nDuring nthe nassessment nphase, ndata nare ncollected. nThe nintervention nphase
nis nwhen nthe nplan nof ncare nis ncarried nout.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
7. Which ngoal nis nmost nappropriate nfor nthe ncollaborative nproblem nof nwound ninfection?
a. The npatient nwill nnot nexhibit nfurther nsigns nof ninfection.
b. Maintain nthe npatient‘s nfluid nintake nat n1000 nmL/8 nhour.
c. The npatient nwill nhave na ntemperature nof n98.F nwithin n2 ndays.
d. Monitor nthe npatient nto ndetect ntherapeutic nresponse nto nantibiotic
n therapy.
ANS: n D
In na ncollaborative nproblem, nthe ngoal nshould nbe nnurse-oriented nand nreflect nthe nnursing
ninterventions nof nmonitoring nor nobserving. nMonitoring nfor ncomplications nsuch nas nfurther
nsigns nof ninfection nis nan nindependent nnursing nrole. nIntake nand noutput nis nan nindependent
nnursing nrole. nMonitoring na npatient‘s ntemperature nis nan nindependent nnursing nrole.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
8. Which nnursing nintervention nis nwritten ncorrectly?
a. Force nfluids nas nnecessary.
b. Observe ninteraction nwith nthe ninfant.
c. Encourage nturning, ncoughing, nand ndeep nbreathing.
d. Assist nto nambulate nfor n10 nminutes nat n8 nAM, n2 nPM, nand n6
nPM.
ANS: n D
Interventions nmight nnot nbe ncarried nout nif nthey nare nnot ndetailed nand nspecific. n―Force
nfluids‖ nis nnot nspecific; nit ndoes nnot nstate nhow nmuch nor nhow noften. nEncouraging nthe npatient
nto nturn, ncough, nand nbreathe ndeeply nis nnot ndetailed nor nspecific. nObserving ninteraction nwith
nthe ninfant ndoes nnot nstate nhow noften nthis nprocedure nshould nbe ndone. nAssisting nthe npatient
nto nambulate nfor n10 nminutes nwithin na ncertain ntimeframe nis nspecific.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
9. The npatient nmakes nthe nstatement: n―I‘m nafraid nto ntake nthe nbabynhome ntomorrow.‖
, Which nresponse nby nthe nnurse nwould nbe nthe nmost ntherapeutic?
n
a. ―You‘re nafraid nto ntake nthe nbaby nhome?‖
b. ―Don‘t nyou nhave na nmother nwho ncan ncome nand nhelp?‖
c. ―You nshould nread nthe nliterature nIngave nyou nbefore nyou nleave.‖
d. ―Inwas nscared nwhen nIntook nmynfirst nbabynhome, nbut neverything nworked nout.‖
ANS: n A
This nresponse nuses nreflection nto nshow nconcern nand nopen ncommunication. nThe nother
nchoices nare nblocks nto ncommunication. nAsking nif nthe npatient nhas na nmother nwho ncan ncome
nand nassist nblocks nfurther ncommunication nwith nthe npatient. nTelling nthe npatient nto nread nthe
nliterature nbefore nleaving ndoes nnot nallow nthe npatient nto nexpress nher nfeelings nfurther.
nSharing n your nown nbirth nexperience nis ninappropriate.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nImplementation nMSC: n Patient nNeeds: nPsychosocial nIntegrity
10. The nnurse nis nwriting nan nexpected noutcome nfor nthe nnursing ndiagnosis—acute npain nrelated
nto ntissue ntrauma, nsecondary nto nvaginal nbirth, nas nevidenced nby npatient nstating npain nof n8
non na nscale nof n10. nWhich nexpected noutcome nis ncorrectly nstated nfor nthis nproblem?
a. Patient nwill nstate nthat npain nis na n2 non na nscale nof n10.
b. Patient nwill nhave na nreduction nin npain nafter nadministration nof nthe nprescribed
analgesic.
c. Patient nwill nstate nan nabsence nof npain n1 nhour nafter nadministration nof nthe nprescribed
analgesic.
d. Patient nwill nstate nthat npain nis na n2 non na nscale nof n10, n1 nhour nafter nthe nadministration
nof
the nprescribed nanalgesic.
ANS: n D
The noutcome nshould nbe npatient-centered, nmeasurable, nrealistic, nand nattainable nand nwithin
na nspecified ntimeframe. nPatient nstating nthat nher npain nis nnow n2 non na nscale nof n10 nlacks na
ntimeframe. nPatient nhaving na nreduction nin npain nafter nadministration nof nthe nprescribed
nanalgesic nlacks na nmeasurement. nPatient nstating nan nabsence nof npain n1 nhour nafter nthe
nadministration nof nprescribed nanalgesic nis nunrealistic.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nPhysiologic nIntegrity
11. Which nnursing ndiagnosis nshould nthe nnurse nidentify nas na npriority nfor na npatient nin
nactive nlabor?
a. Risk nfor nanxiety nrelated nto nupcoming nbirth
b. Risk nfor nimbalanced nnutrition nrelated nto nNPO nstatus
c. Risk nfor naltered nfamily nprocesses nrelated nto nnew naddition nto nthe nfamily
d. Risk nfor ninjury n(maternal) nrelated nto naltered nsensations nand npositional nor
nphysical
changes
ANS: n D
The nnurse nshould ndetermine nwhich nproblem nneeds nimmediate nattention. nRisk nfor ninjury nis
nthe nproblem nthat nhas nthe npriority nat nthis ntime nbecause nit nis na nsafety nproblem. nRisk nfor
nanxiety, nimbalanced nnutrition, nand naltered nfamily nprocesses nare nnot nthe npriorities nat nthis
ntime.
Murray Foundations of Maternal-Newborn and Women's Health Nursing, 8th
n n n n n n n n
Edition
n
Chapter 01: n
MULTIPLE nCHOICE
1. A nnurse neducator nis nteaching na ngroup nof nnursing nstudents nabout nthe nhistory nof
family-centered nmaternity ncare. nWhich nstatement nshould nthe nnurse ninclude nin nthe nteaching
nsession?
a. The nSheppard-Towner nAct nof n1921 npromoted nfamily-centered ncare.
b. Changes nin npharmacologic nmanagement nof nlabor nprompted nfamily-centered ncare.
c. Demands nby nphysicians nfor nfamily ninvolvement nin nchildbirth nincreased nthe
npractice
of nfamily-centered ncare.
d. Parental nrequests nthat ninfants nbe nallowed nto nremain nwith nthem nrather nthan nin na
nursery ninitiated nthe npractice nof nfamily-centered ncare.
ANS: n D
As nresearch nbegan nto nidentify nthe nbenefits nof nearly, nextended nparent–infant ncontact,
nparents nbegan nto ninsist nthat nthe ninfant nremain nwith nthem. nThis ngradually ndeveloped ninto
nthe npractice nof nrooming-in nand nfinally nto nfamily-centered nmaternity ncare. nThe nSheppard-
Towner nAct nprovided nfunds nfor nstate-managed nprograms nfor nmothers nand nchildren nbut
ndid nnot npromote nfamily-centered ncare. nThe nchanges nin npharmacologic nmanagement nof
nlabor nwere nnot na nfactor nin nfamily-centered nmaternity ncare. nFamily-centered ncare nwas na
nrequest nby nparents, nnot nphysicians.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nHealth nPromotion nand nMaintenance
2. Expectant nparents nask na nprenatal nnurse neducator, n―Which nsetting nfor nchildbirth nlimits nthe
amount nof nparent–infant ninteraction?‖ nWhich nanswer nshould nthe nnurse nprovide nfor
n
these nparents nin norder nto nassist nthem nin nchoosing nan nappropriate nbirth nsetting?
n
a. Birth ncenter
b. Home nbirth
c. Traditional nhospital nbirth
d. Labor, nbirth, nand nrecovery nroom
ANS: n C
In nthe ntraditional nhospital nsetting, nthe nmother nmay nsee nthe ninfant nfor nonly nshort nfeeding
nperiods, nand nthe ninfant nis ncared nfor nin na nseparate nnursery. nBirth ncenters nare nset nup nto
nallow nan nincrease nin nparent–infant ncontact. nHome nbirths nallow nthe ngreatest namount nof
parent–infant ncontact. nThe nlabor, nbirth, nrecovery, nand npostpartum nroom nsetting nallows nfor
nincreased nparent–infant ncontact.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nHealth nPromotion nand nMaintenance
,3. Which nstatement nbest ndescribes nthe nadvantage nof na nlabor, nbirth, nrecovery, nand
postpartum n(LDRP) nroom?
n
a. The nfamily nis nin na nfamiliar nenvironment.
b. They nare nless nexpensive nthan ntraditional nhospital nrooms.
c. The ninfant nis nremoved nto nthe nnursery nto nallow nthe nmother nto nrest.
d. The nwoman‘s nsupport nsystem nis nencouraged nto nstay nuntil
ndischarge.
ANS: n D
Sleeping nequipment nis nprovided nin na nprivate nroom. nA nhospital nsetting nis nnever na nfamiliar
nenvironment nto nnew nparents. nAn nLDRP nroom nis nnot nless nexpensive nthan na ntraditional
nhospital nroom. nThe nbaby nremains nwith nthe nmother nat nall ntimes nand nis nnot nremoved nto nthe
nnursery nfor nroutine ncare nor ntesting. nThe nfather nor nother ndesignated nmembers nof nthe
nmother‘s nsupport nsystem nare nencouraged nto nstay nat nall ntimes.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nAssessment nMSC: n Patient nNeeds: nHealth nPromotion nand nMaintenance
4. Which nnursing nintervention nis nan nindependent nfunction nof nthe nprofessional nnurse?
a. Administering noral nanalgesics
b. Requesting ndiagnostic nstudies
c. Teaching nthe npatient nperineal ncare
d. Providing nwound ncare nto na nsurgical
n incision
ANS: n C
Nurses nare nnow nresponsible nfor nvarious nindependent nfunctions, nincluding nteaching,
ncounseling, nand nintervening nin nnonmedical nproblems. nInterventions ninitiated nby nthe
nphysician nand ncarried nout nby nthe nnurse nare ncalled ndependent nfunctions. nAdministrating
noral nanalgesics nis na ndependent nfunction; nit nis ninitiated nby na nphysician nand ncarried nout nby na
nnurse. nRequesting ndiagnostic nstudies nis na ndependent nfunction. nProviding nwound ncare nis na
ndependent nfunction; nhowever, nthe nphysician nprescribes nthe ntype nof nwound ncare nthrough
ndirect norders nor nprotocol.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nAssessment nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
5. Which nresponse nbynthe nnurse nis nthe nmost ntherapeutic nwhen nthe npatient nstates, n―I‘m nso
afraid nto nhave na ncesarean nbirth‖?
n
a. ―Everything nwill nbe nOK.‖
b. ―Don‘t nworrynabout nit. nIt nwill nbe nover nsoon.‖
c. ―What nconcerns nyou nmost nabout na ncesarean nbirth?‖
d. ―The nphysician nwill nbe nin nlater nand nyou ncan ntalk nto nhim.‖
ANS: n C
The nresponse, n―What nconcerns nyou nmost nabout na ncesarean nbirth‖ nfocuses non nwhat nthe
npatient nis nsaying nand nasks nfor nclarification, nwhich nis nthe nmost ntherapeutic nresponse. nThe
nresponse, n―Everything nwill nbe nok‖ nis nbelittling nthe npatient‘s nfeelings. nThe nresponse,
n―Don‘t nworry nabout nit. nIt nwill nbe nover nsoon‖ nwill nindicate nthat nthe npatient‘s nfeelings nare
nnot nimportant. nThe nresponse, n―The nphysician nwill nbe nin nlater nand nyou ncan ntalk nto nhim‖
ndoes nnot nallow nthe npatient nto nverbalize nher nfeelings nwhen nshe nwishes nto ndo nthat.
DIF: Cognitive nLevel: nApplication OBJ: n n Nursing nProcess nStep: nImplementation
, MSC: n Patient nNeeds: nPsychosocial nIntegrity
6. In nwhich nstep nof nthe nnursing nprocess ndoes nthe nnurse ndetermine nthe nappropriate
interventions nfor nthe nidentified nnursing ndiagnosis?
n
a. Planning
b. Evaluation
c. Assessment
d. Intervention
ANS: n A
The nthird nstep nin nthe nnursing nprocess ninvolves nplanning ncare nfor nproblems nthat nwere
nidentified nduring nassessment. nThe nevaluation nphase nis ndetermining nwhether nthe ngoals
nhave nbeen nmet. nDuring nthe nassessment nphase, ndata nare ncollected. nThe nintervention nphase
nis nwhen nthe nplan nof ncare nis ncarried nout.
DIF: Cognitive nLevel: nUnderstanding OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
7. Which ngoal nis nmost nappropriate nfor nthe ncollaborative nproblem nof nwound ninfection?
a. The npatient nwill nnot nexhibit nfurther nsigns nof ninfection.
b. Maintain nthe npatient‘s nfluid nintake nat n1000 nmL/8 nhour.
c. The npatient nwill nhave na ntemperature nof n98.F nwithin n2 ndays.
d. Monitor nthe npatient nto ndetect ntherapeutic nresponse nto nantibiotic
n therapy.
ANS: n D
In na ncollaborative nproblem, nthe ngoal nshould nbe nnurse-oriented nand nreflect nthe nnursing
ninterventions nof nmonitoring nor nobserving. nMonitoring nfor ncomplications nsuch nas nfurther
nsigns nof ninfection nis nan nindependent nnursing nrole. nIntake nand noutput nis nan nindependent
nnursing nrole. nMonitoring na npatient‘s ntemperature nis nan nindependent nnursing nrole.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
8. Which nnursing nintervention nis nwritten ncorrectly?
a. Force nfluids nas nnecessary.
b. Observe ninteraction nwith nthe ninfant.
c. Encourage nturning, ncoughing, nand ndeep nbreathing.
d. Assist nto nambulate nfor n10 nminutes nat n8 nAM, n2 nPM, nand n6
nPM.
ANS: n D
Interventions nmight nnot nbe ncarried nout nif nthey nare nnot ndetailed nand nspecific. n―Force
nfluids‖ nis nnot nspecific; nit ndoes nnot nstate nhow nmuch nor nhow noften. nEncouraging nthe npatient
nto nturn, ncough, nand nbreathe ndeeply nis nnot ndetailed nor nspecific. nObserving ninteraction nwith
nthe ninfant ndoes nnot nstate nhow noften nthis nprocedure nshould nbe ndone. nAssisting nthe npatient
nto nambulate nfor n10 nminutes nwithin na ncertain ntimeframe nis nspecific.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nSafe nand nEffective nCare nEnvironment
9. The npatient nmakes nthe nstatement: n―I‘m nafraid nto ntake nthe nbabynhome ntomorrow.‖
, Which nresponse nby nthe nnurse nwould nbe nthe nmost ntherapeutic?
n
a. ―You‘re nafraid nto ntake nthe nbaby nhome?‖
b. ―Don‘t nyou nhave na nmother nwho ncan ncome nand nhelp?‖
c. ―You nshould nread nthe nliterature nIngave nyou nbefore nyou nleave.‖
d. ―Inwas nscared nwhen nIntook nmynfirst nbabynhome, nbut neverything nworked nout.‖
ANS: n A
This nresponse nuses nreflection nto nshow nconcern nand nopen ncommunication. nThe nother
nchoices nare nblocks nto ncommunication. nAsking nif nthe npatient nhas na nmother nwho ncan ncome
nand nassist nblocks nfurther ncommunication nwith nthe npatient. nTelling nthe npatient nto nread nthe
nliterature nbefore nleaving ndoes nnot nallow nthe npatient nto nexpress nher nfeelings nfurther.
nSharing n your nown nbirth nexperience nis ninappropriate.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nImplementation nMSC: n Patient nNeeds: nPsychosocial nIntegrity
10. The nnurse nis nwriting nan nexpected noutcome nfor nthe nnursing ndiagnosis—acute npain nrelated
nto ntissue ntrauma, nsecondary nto nvaginal nbirth, nas nevidenced nby npatient nstating npain nof n8
non na nscale nof n10. nWhich nexpected noutcome nis ncorrectly nstated nfor nthis nproblem?
a. Patient nwill nstate nthat npain nis na n2 non na nscale nof n10.
b. Patient nwill nhave na nreduction nin npain nafter nadministration nof nthe nprescribed
analgesic.
c. Patient nwill nstate nan nabsence nof npain n1 nhour nafter nadministration nof nthe nprescribed
analgesic.
d. Patient nwill nstate nthat npain nis na n2 non na nscale nof n10, n1 nhour nafter nthe nadministration
nof
the nprescribed nanalgesic.
ANS: n D
The noutcome nshould nbe npatient-centered, nmeasurable, nrealistic, nand nattainable nand nwithin
na nspecified ntimeframe. nPatient nstating nthat nher npain nis nnow n2 non na nscale nof n10 nlacks na
ntimeframe. nPatient nhaving na nreduction nin npain nafter nadministration nof nthe nprescribed
nanalgesic nlacks na nmeasurement. nPatient nstating nan nabsence nof npain n1 nhour nafter nthe
nadministration nof nprescribed nanalgesic nis nunrealistic.
DIF: Cognitive nLevel: nApplication OBJ: n Nursing nProcess nStep:
nPlanning nMSC: n Patient nNeeds: nPhysiologic nIntegrity
11. Which nnursing ndiagnosis nshould nthe nnurse nidentify nas na npriority nfor na npatient nin
nactive nlabor?
a. Risk nfor nanxiety nrelated nto nupcoming nbirth
b. Risk nfor nimbalanced nnutrition nrelated nto nNPO nstatus
c. Risk nfor naltered nfamily nprocesses nrelated nto nnew naddition nto nthe nfamily
d. Risk nfor ninjury n(maternal) nrelated nto naltered nsensations nand npositional nor
nphysical
changes
ANS: n D
The nnurse nshould ndetermine nwhich nproblem nneeds nimmediate nattention. nRisk nfor ninjury nis
nthe nproblem nthat nhas nthe npriority nat nthis ntime nbecause nit nis na nsafety nproblem. nRisk nfor
nanxiety, nimbalanced nnutrition, nand naltered nfamily nprocesses nare nnot nthe npriorities nat nthis
ntime.
