Maternal-Child Nursing 3rd Edition Test Bank

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Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
McKinney: Maternal-Child Nursing, 3rd Edition
Test Bank
Chapter 1: Foundations of Maternity, Women’s Health, and Child Health Nursing
MULTIPLE CHOICE
1. Which factor significantly contributed to the shift from home births to hospital births in the early
twentieth century?
a. Puerperal sepsis was identified as a risk factor in labor and delivery.
b. Forceps were developed to facilitate difficult births.
c. The importance of early parental-infant contact was identified.
d. The number of hospital births decreased.
ANS: B
A Puerperal sepsis has been a known problem for generations. In the late nineteenth century,
Semmelweis discovered how it could be prevented.
B The development of forceps to facilitate difficult births by physicians was a strong factor in the
decrease of home births and increase of hospital births.
C The shift to hospital births decreased the parental-infant contact.
D With the shift toward hospital births, the numbers increased.
DIF: Cognitive Level: Knowledge REF: p. 2
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Safe and Effective Care Environment
2. Family-centered maternity care developed in response to:
a. demands by physicians for family involvement in childbirth.
b. the Sheppard-Towner Act of 1921.
c. parental requests that infants be allowed to remain with them rather than in a
nursery.
d. changes in pharmacologic management of labor.
ANS: C
A Family-centered care was a request by parents, not physicians.
B The Sheppard-Towner Act provided funds for state-managed programs for mothers and
children.
C As research began to identify the benefits of early extended parent-infant contact, parents
began to insist that the infant remain with them. This gradually developed into the practice of
rooming-in and finally to family-centered maternity care.
D The changes in pharmacologic management of labor were not a factor in family-centered
maternity care.
DIF: Cognitive Level: Knowledge REF: pp. 3-4
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity

Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-2
3. Which setting for childbirth allows the least amount of parent-infant contact?
a. Labor/delivery/recovery/postpartum room
b. Birth center
c. Traditional hospital birth
d. Home birth
ANS: C
A The labor/delivery/recovery/postpartum room setting allows increased parent-infant contact.
B Birth centers are set up to allow an increase in parent-infant contact.
C In the traditional hospital setting, the mother may see the infant for only short feeding periods,
and the infant is cared for in a separate nursery.
D Home births allow an increase in parent-infant contact.
DIF: Cognitive Level: Knowledge REF: p. 3
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Health Promotion and Maintenance
4. As a result of changes in health care delivery and funding, a current trend seen in the pediatric
setting is:
a. increased hospitalization of children.
b. decreased number of children living in poverty.
c. an increase in ambulatory care.
d. decreased use of managed care.
ANS: C
A Hospitalization for children has decreased.
B Health care delivery has not altered the number of children living in poverty.
C One effect of managed care has been that pediatric health care delivery has shifted
dramatically from the acute care setting to the ambulatory setting. One of the biggest changes in
health care has been the growth of managed care. The number of hospital beds being used has
decreased as more care is given in outpatient settings and in the home. The number of children
living in poverty has increased over the last decade.
D Managed care has increased in order to control cost.
DIF: Cognitive Level: Knowledge REF: p. 6
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
5. The Women-Infants-Children (WIC) program provides:
a. well-child examinations for infants and children living at the poverty level.
b. immunizations for high-risk infants and children.
c. screening for infants with developmental disorders.
d. supplemental food supplies to low-income women who are pregnant or
breastfeeding.
ANS: D

Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-3
A Medicaid’s Early and Periodic Screening, Diagnosis, and Treatment Program provides for
well-child examinations and for treatment of any medical problems diagnosed during such
checkups.
B Children in the WIC program are often linked with immunizations, but that is not the primary
focus of the program.
C Public Law 99-457 provides financial incentives to states to establish comprehensive early
intervention services for infants and toddlers with, or at risk for, developmental disabilities.
D WIC is a federal program that provides supplemental food supplies to low-income women
who are pregnant or breastfeeding and to their children until age 5 years.
DIF: Cognitive Level: Comprehension REF: p. 9
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity
6. In most states, adolescents who are not emancipated minors must have the permission of their
parents before:
a. treatment for drug abuse.
b. treatment for sexually transmitted diseases (STDs).
c. accessing birth control.
d. surgery.
ANS: D
A Most states allow minors to obtain treatment for drug or alcohol abuse without parental
consent.
B Most states allow minors to obtain treatment for STDs without parental consent.
C In most states minors are allowed access to birth control without parental consent.
D If a minor receives surgery without proper informed consent, assault and battery charges
against the care provider can result. This does not apply to an emancipated minor (a minor child
who has the legal competency of an adult because of circumstances involving marriage, divorce,
parenting of a child, living independently without parents, or enlistment in the armed services).
DIF: Cognitive Level: Application REF: p. 18
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
7. The maternity nurse should have a clear understanding of the correct use of a clinical pathway.
One characteristic of clinical pathways is that they:
a. are developed and implemented by nurses.
b. are used primarily in the pediatric setting.
c. set specific time lines for sequencing interventions.
d. are part of the nursing process.
ANS: C
A Clinical pathways are developed by multiple health care professionals and reflect
interdisciplinary interventions.
B They are used in multiple settings and for patients throughout the life span.
C Clinical pathways measure outcomes of patient care. Each pathway outlines specific time lines
for sequencing interventions.

Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-4
D The steps of the nursing process are assessment, diagnosis, planning, intervention, and
evaluation.
DIF: Cognitive Level: Application REF: p. 7
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
8. The fastest-growing group of homeless people is:
a. men and women preparing for retirement.
b. migrant workers.
c. single women and their children.
d. intravenous substance abusers.
ANS: C
A Most people contemplating retirement have made provisions.
B Migrant workers may seek health care only when absolutely necessary; however, not all are
homeless.
C Pregnancy and birth, especially for a teenager, are important contributing factors for becoming
homeless.
D Not all substance abusers are homeless.
DIF: Cognitive Level: Knowledge REF: p.14
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity
9. The United States ranks twenty-eighth in infant mortality rates of the world. Which factor has a
significant impact on decreasing the mortality rate of infants?
a. Resolving all language and cultural differences
b. Enrolling the pregnant woman in the Medicaid program by the eighth month of
pregnancy
c. Ensuring early and adequate prenatal care
d. Providing more women's shelters
ANS: C
A Language and cultural differences are not infant mortality issues but must be addressed to
improve overall health care.
B 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.
C Because preterm infants form the largest category of those needing expensive intensive care,
early pregnancy intervention is essential for decreasing infant mortality rates.
D The women in shelters have the same difficulties in obtaining health care as do other poor
people, particularly lack of transportation and inconvenient hours of the clinics.
DIF: Cognitive Level: Comprehension REF: p. 2
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-5
10. The intrapartum woman sees no need for an admission fetal monitoring strip. If she continues to
refuse, what is the first action the nurse should take?
a. Consult with the family of the woman.
b. Notify the physician.
c. Document the woman's refusal in the nurse's notes.
d. Make a referral to the hospital ethics committee.
ANS: B
A The client must be allowed to make choices voluntarily without undue influence or coercion
from others.
B Clients must be allowed to make choices voluntarily without undue influence or coercion from
others. The physician, especially if unaware of the client's decision, should be notified
immediately. The nurse should notify the physician of the refusal of the agency's protocol and
document all aspects of the explanations given by the nurse, as well as any instructions from the
physician.
C Documentation is important, but it should not be the first action.
D Fetal monitoring is not usually considered an ethical problem.
DIF: Cognitive Level: Application REF: p. 18
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe and Effective Care Environment
11. Which statement is true regarding the "quality assurance" or "incident" report?
a. The report assures the legal department that no problem exists.
b. Reports are a permanent part of the patient's chart.
c. The nurse's notes should contain, "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
A The report is a warning to the legal department to be prepared for a potential legal action.
B Incident reports are not a part of the patient's chart.
C Incident reports are not mentioned in the nurse's notes.
D Documentation on the chart should include all factual information regarding the client's
condition that would be recorded in any situation. Incident reports are not mentioned in the
nurse's notes. The nurse completes an incident report when something occurs that might result in
a legal action against the clinic or hospital or is a variance from the standard of care.
DIF: Cognitive Level: Application REF: p. 17
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe and Effective Care Environment
12. Which of these situations best reflects the deontologic theory?
a. Initiating resuscitative measures on a 90-year-old patient with terminal cancer
b. Using experimental medications for the treatment of acquired immunodeficiency
syndrome (AIDS)
c. Supporting the transplant of fetal tissue and organs
d. Approving of a physician-assisted suicide

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Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-6
ANS: A
A In the deontologic theory, life must be maintained at all costs, regardless of quality of life.
B In the deontologic theory, life must be maintained at all costs, regardless of quality of life.
C In the deontologic theory, life must be maintained at all costs, regardless of quality of life.
D In the deontologic theory, life must be maintained at all costs, regardless of quality of life.
DIF: Cognitive Level: Comprehension REF: p. 1
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
13. Elective abortion is considered an ethical issue because:
a. abortion law is unclear about a woman's constitutional rights.
b. the Supreme Court ruled that life begins at conception.
c. a conflict exists between the rights of the woman and the rights of the fetus.
d. it requires third-party consent.
ANS: C
A Abortion laws are clear concerning a woman’s constitutional rights.
B The Supreme Court has not ruled on when life begins.
C Elective abortion is an ethical dilemma because two opposing courses of action are available.
D Abortion does not require third-party consent.
DIF: Cognitive Level: Comprehension REF: p. 12
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Safe and Effective Care Environment
14. Which woman would be most likely to seek prenatal care?
a. A 15-year-old who tells her friends, "I don't believe I am pregnant"
b. A 20-year-old who is in her first pregnancy and has access to a free prenatal clinic
c. A 28-year-old who is in her second pregnancy and abuses drugs and alcohol
d. A 30-year-old who is in her fifth pregnancy and delivered her last infant at home
with the help of her mother and sister
ANS: B
A Being in denial about the pregnancy will prevent her from seeking health care.
B 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.
C Substance abusers are less likely to seek health care.
D Some women see pregnancy and delivery as a natural occurrence and do not seek health care.
DIF: Cognitive Level: Comprehension REF: pp. 8, 15
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance
15. A woman who delivered her baby 6 hours ago complains of headache and dizziness. The nurse
administers an analgesic but does not perform any assessments. The woman then has a grand mal
seizure, falls out of bed, and fractures her femur. How would the actions of the nurse be
interpreted in relation to standards of care?

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Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-7
a. Negligent because the nurse failed to assess the woman for possible complications
b. Negligent because the nurse medicated the woman
c. Not negligent because the woman had signed a waiver concerning the use of side
rails
d. Not negligent because the woman did not inform the nurse of her symptoms as
soon as they occurred
ANS: A
A By not assessing the woman, the nurse failed to meet the established standards of care. The
first element of negligence relates to whether the nurse has a duty to provide care to the woman.
The care that the nurse provides must meet the established standards of care.
B By not first assessing the woman, the nurse does not meet the established standards of care.
C The nurse could be found negligent.
D The nurse is responsible for assessing the woman.
DIF: Cognitive Level: Application REF: p. 17
OBJ: Nursing Process Step: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
16. What client situation fails to meet the first requirement of informed consent?
a. The client does not understand the physician's explanations.
b. The physician gives the client only a partial list of possible side effects and
complications.
c. The client is confused and disoriented.
d. The client signs a consent form because his wife tells him to.
ANS: C
A Understanding is an important element of the consent, but first the client has to be competent
to sign.
B Full disclosure of information is an important element of the consent, but first the client has to
be competent to sign.
C The first requirement of informed consent is that the client must be competent to make
decisions about health care.
D Voluntary consent is an important element of the consent, but first the client has to be
competent to sign.
DIF: Cognitive Level: Comprehension REF: p. 18
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Safe and Effective Care Environment
17. Which situation reflects a potential ethical dilemma for the nurse?
a. A nurse administers analgesics to a client with cancer as often as the physician's
order allows.
b. A neonatal nurse provides nourishment and care to a newborn having a defect that
is incompatible with life.
c. A labor nurse, whose religion opposes abortion, is asked to assist with an elective
abortion.

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Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-8
d. A postpartum nurse provides information about adoption to a new mother who
feels she cannot adequately care for her infant.
ANS: C
A There is no element of conflict for the nurse, therefore a dilemma does not exist.
B There is no element of conflict for the nurse, therefore a dilemma does not exist.
C A dilemma exists in this situation because the nurse is being asked to assist with a procedure
that she or he believes is morally wrong. The other situations do not contain elements of conflict
for the nurse.
D There is no element of conflict for the nurse, therefore a dilemma does not exist.
DIF: Cognitive Level: Analysis REF: p. 11
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Many communities now offer the availability of free-standing birth centers to provide care for
low-risk women during pregnancy, birth, and postpartum. When counseling the newly pregnant
woman regarding this option, the nurse should be aware that this type of care setting includes
which advantages? Choose those that apply.
a. Less expensive than acute-care hospitals
b. Access to follow-up care for 6 weeks postpartum
c. Equipped for obstetric emergencies
d. Safe, home-like births in a familiar setting
e. Staffing by lay midwives
ANS: A, B, D
Correct A, B, D. Women who are at low risk and desire a safe, home-like birth are very satisfied
with this type of care setting. The new mother may return to the birth center for postpartum
follow-up care, breastfeeding assistance, and family planning information for 6 weeks
postpartum. Since birth centers do not incorporate advanced technologies into their services,
costs are significantly less than a hospital setting.
Incorrect C, E. The major disadvantage of this care setting is that these facilities are not
equipped to handle obstetric emergencies. Should unforeseen difficulties occur, the woman must
be transported by ambulance to the nearest hospital. Birth centers are usually staffed by certified
nurse-midwives (CNMs); however, in some states lay midwives may provide this service.
DIF: Cognitive Level: Comprehension REF: p. 4
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
2. In an effort to reduce prohibitive health care costs, many facilities have incorporated the use of
unlicensed assistive personnel into their care delivery model. Nurses supervising these
employees must be aware of what each such employee is competent to do within his or her scope
of practice. Which tasks can be delegated with supervision? Choose the tasks that apply.
a. Blood draws

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Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
1-9
b. Medication administration
c. Nursing assessment
d. Housekeeping tasks
e. Other diagnostic tests, such as electrocardiograms (ECGs or EKGs)
ANS: A, B, D, E
Correct A, B, D, E. With proper supervision and adequate instruction, unlicensed assistive
personnel may perform all of these functions. In long-term care settings, these personnel are
often responsible for medication administration under the direction of the registered nurse (RN).
Incorrect C. The nurse is always responsible for client assessments and must make critical
judgments to ensure client safety. Use of the expert nurse to complete housekeeping or other
mundane tasks is not a good use of human resources. For more information about the use of
unlicensed personnel, refer to www.awhonn.org.
DIF: Cognitive Level: Application REF: p. 20
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Safe and Effective Care Environment

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Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
McKinney: Maternal-Child Nursing, 3rd Edition
Test Bank
Chapter 2: The Nurse’s Role in Maternity, Women’s Health, and Pediatric Nursing
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.
b. Present complex subject material first, while the family is alert and ready to learn.
c. Families should be taught by using medical jargon so they will be able to
understand the technical language used by physicians.
d. Learning is best accomplished using the lecture format.
ANS: A
A Praise and positive are particularly important when a family is trying to master a frustrating
task, such as breastfeeding.
B Learning is enhanced when the teaching is structured to present the simple tasks before the
complex material.
C Even though a family may understand English fairly well, they may not understand the
medical terminology or slang terms.
D A lively discussion stimulates more learning than a straight lecture, which tends to inhibit
questions.
DIF: Cognitive Level: Application REF: p. 25
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Health Promotion and Maintenance
2. When addressing the questions of a newly pregnant woman, the nurse can explain that the
certified nurse-midwife is qualified to perform:
a. regional anesthesia. c. vaginal deliveries.
b. cesarean deliveries. d. internal versions.
ANS: C
A Regional anesthesia must be performed by a physician.
B Cesarean deliveries must be performed by a physician.
C The midwife is qualified to deliver infants vaginally in uncomplicated pregnancies.
D Internal versions must be performed by a physician.
DIF: Cognitive Level: Knowledge REF: pp. 26-27
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Safe and Effective Care Environment
3. Which nursing intervention is an independent function of the nurse?
a. Administering oral analgesics
b. Teaching the client perineal care

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Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
2-2
c. Requesting diagnostic studies
d. Providing wound care to a surgical incision
ANS: B
A Administering oral analgesics is a dependent function; it is initiated by a physician and carried
out by the nurse.
B 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.
C Requesting diagnostic studies is a dependent function.
D Providing wound care is a dependent function; it is usually initiated by the physician through
direct orders or protocol.
DIF: Cognitive Level: Comprehension REF: p. 25
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. Which response by the nurse to the client's statement, "I'm afraid to have a cesarean birth,"
would be the most therapeutic?
a. "What concerns you most about a cesarean birth?"
b. "Everything will be OK."
c. "Don't worry about it. It will be over soon."
d. "The doctor will be in later, and you can talk to him."
ANS: A
A Focusing on what the client is saying and asking for clarification is the most therapeutic
response.
B This response is belittling the client’s feelings.
C This response will indicate that the client’s feelings are not important.
D This response does not allow the client to verbalize her feelings when she desires.
DIF: Cognitive Level: Application REF: pp. 27-29
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Psychosocial Integrity
5. To evaluate the client's learning about performing infant care, the nurse should:
a. demonstrate infant care procedures.
b. allow the client to verbalize the procedure.
c. observe the client as she performs the procedure.
d. routinely assess the infant for cleanliness.
ANS: C
A Demonstration is an excellent teaching method, but not an evaluation method.
B During verbalization of the procedure, the nurse may not pick up on techniques that are
incorrect. It is not the best tool for evaluation.
C The client's ability to perform the procedure correctly under the nurse's supervision is the best
method of evaluation.

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Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
2-3
D This will not ensure that the proper procedure is carried out. The nurse may miss seeing unsafe
techniques being used.
DIF: Cognitive Level: Application REF: p. 32
OBJ: Nursing Process Step: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
6. What situation is most conducive to learning?
a. A teacher who speaks very little Spanish is teaching a class of Latino students.
b. A class is composed of students of various ages and educational backgrounds.
c. An auditorium is being used as a classroom for 300 students.
d. An Asian nurse provides nutritional information to a group of pregnant Asian
women.
ANS: D
A 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, informal usage of words, or medical words. The teacher should be fluent in
the language of the student.
B Developmental levels and educational levels influence how a person learns best. In order for
the teacher to best present information, it is best for the class to be of the same levels.
C A large class is not conducive to learning. It does not allow for questions, and the teacher is
not able to see the nonverbal from the students to ensure understanding.
D A client's 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 client's cultural
beliefs.
DIF: Cognitive Level: Application REF: p. 25
OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity
7. The step of the nursing process in which the nurse determines the appropriate interventions for
the identified nursing diagnosis is called:
a. assessment. c. intervention.
b. planning. d. evaluation.
ANS: B
A During the assessment phase, data are collected.
B The third step in the nursing process involves planning care for problems that were identified
during assessment.
C The intervention phase is when the plan of care is carried out.
D The evaluation phase is determining if the goals have been met.
DIF: Cognitive Level: Knowledge REF: p. 32
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
8. Which goal is most appropriate for the collaborative problem of wound infection?

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Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
2-4
a. The client will have a temperature of 98.6° F within 2 days.
b. Maintain the client's fluid intake at 1000 mL per 8 hours.
c. The client will not exhibit further signs of infection.
d. Monitor the client to detect therapeutic response to antibiotic therapy.
ANS: D
A Monitoring a client’s temperature is an independent nursing role.
B Intake and output is an independent nursing role.
C Monitoring for complications is an independent nursing role.
D In a collaborative problem, the goal should be nurse oriented and reflect the nursing
interventions of monitoring or observing. In collaborative problems other team members are
involved, such as prescribing antibiotics.
DIF: Cognitive Level: Comprehension REF: pp. 32-33
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
9. Which nursing intervention is correctly written?
a. Encourage turning, coughing, and deep breathing.
b. Force fluids as necessary.
c. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM.
d. Observe interaction with infant.
ANS: C
A This intervention does not state how often this procedure should be done.
B “Force fluids” is not specific; it does not state how much.
C Interventions may not be carried out unless they are detailed and specific.
D This intervention is not detailed and specific.
DIF: Cognitive Level: Comprehension REF: p. 32
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
10. What part of the nursing process includes the collection of data on vital signs, allergies, sleep
patterns, and feeding behaviors?
a. Assessment c. Implementation
b. Planning d. Evaluation
ANS: A
A Assessment is the gathering of baseline data.
B Planning is based on baseline data and physical assessment.
C Implementation is the initiation and completion of nursing interventions.
D Evaluation is the last step in the nursing process and involves determining if the goals were
met.
DIF: Cognitive Level: Comprehension REF: p. 30
OBJ: Nursing Process Step: Assessment
MSC: Client Needs: Health Promotion and Maintenance

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Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
2-5
11. Which step in the nursing process identifies the basis or cause of the patient's problem?
a. Intervention c. Nursing diagnosis
b. Expected outcome d. Evaluation
ANS: C
A Interventions are actions taken to meet the problem.
B Expected outcome is a statement of the goal.
C A nursing diagnosis states the problem and its cause (the “related to”).
D Evaluation determines whether the goal has been met.
DIF: Cognitive Level: Knowledge REF: p. 32
OBJ: Nursing Process Step: Planning
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Today’s nurse often assumes the role of teacher or educator. Client teaching begins early in the
childbirth process and continues throughout the postpartum period. Which strategies would be
best to employ for a nurse working with a teen mother? Choose those that apply.
a. Computer-based learning
b. Videos
c. Printed material
d. Group discussion
e. Models
ANS: A, B, C, D, E
Correct A, B, C, D, E. A number of factors influence learning at any age. One of the most
significant considerations is developmental level. Teenage parents often have very different
concerns and learn in a different way than older parents. Often grandparents are also involved in
the rearing of these children and must be able to review and understand the material. There is a
wealth of new information that may not have been available when they became parents.
Incorrect All are correct.
DIF: Cognitive Level: Application REF: pp. 25-26
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Health Promotion and Maintenance
COMPLETION
1. Interventions, modalities, professions, theories, applications, or practices that are not currently
part of the conventional medical system in North American culture are often referred to as
____________________ or ____________________ medicine.
ANS:
complementary or alternative (CAM)

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Test Bank
Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc.
2-6
For many people such therapies are not considered alternative, because they are mainstream in
their culture. Others combine them with traditional medical practices, thereby using an
integrative approach. A continued concern is client safety. Some clients who use these
techniques may delay necessary care, and others may take herbal or other remedies that might
become toxic when used in combination with prescription drugs or taken in excess.
DIF: Cognitive Level: Comprehension REF: p. 33
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

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