A patient who is 38 weeks pregnant is admitted to the hospital in active labor.
On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?
Check the patient’s bladder for distention.
Test the patient’s vaginal secretions with nitrazine paper.
Check the patient’s urine for glucose content.
Obtain a specimen of the patient’s vaginal secretions for culture
The Correct Answer is B
Choice A reason: Checking for bladder distention is a secondary nursing assessment to ensure the fetal head can descend properly. However, it does not address the patient's report of leaking fluid. While important for comfort and progress, it lacks the diagnostic priority required to differentiate between urine and amniotic fluid during labor admission.
Choice B reason: This is the priority action to confirm Spontaneous Rupture of Membranes (SROM). Nitrazine paper detects the alkaline pH of amniotic fluid, which turns the paper blue. According to NIH clinical guidelines, distinguishing amniotic fluid from acidic urine is essential to manage infection risks and plan appropriate obstetric interventions for labor.
Choice C reason: Testing for glucose is a metabolic screening tool used to monitor for gestational diabetes or renal threshold changes. It provides no clinical value in determining the status of the amniotic membranes. Following Maslow’s Hierarchy, ensuring physiological safety via membrane assessment takes precedence over routine metabolic urine screenings.
Choice D reason: Obtaining a culture is a diagnostic step for identifying pathogens like Group B Streptococcus, but it is not an initial assessment. Cultures require significant time for results and do not confirm rupture. Rapid bedside tests are the standard initial action to determine if the "bag of water" is broken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A transverse lie means that the baby is lying sideways across the uterus, instead of head-down or breech.
This position makes vaginal delivery impossible and increases the risk of umbilical cord prolapse, which can compromise fetal oxygen supply.Therefore, a cesarean delivery is indicated for a fetus in a transverse lie.
Choice A is wrong because having extremely slender hips does not necessarily mean that a woman cannot deliver vaginally.
The size and shape of the pelvis, not the external appearance, determines the adequacy of the birth canal.A trial of labor may be attempted for women with borderline pelvic measurements.
Choice C is wrong because fetal hyperactivity is not a reason for a cesarean delivery.
Fetal movements may vary depending on the time of day, maternal activity, maternal blood sugar level, and other factors.Fetal well-being can be assessed by fetal heart rate monitoring and biophysical profile.
Choice D is wrong because having a posterior cervix does not indicate the need for a cesarean delivery.
A posterior cervix means that the cervix is tilted toward the back of the uterus, which may make cervical dilation slower and more painful.However, with adequate contractions and maternal pushing, the cervix can move to an anterior position and allow vaginal delivery.
Correct Answer is B
Explanation
The correct answer is choice B.“The placenta was blocking the opening of the womb.”
This statement shows that the patient understands that placenta previa is a condition where the placenta covers or is near the internal os of the cervix, which prevents a safe vaginal delivery.The patient would need a cesarean delivery to avoid bleeding and complications.
Choice A is wrong because it describes placental abruption, not placenta previa.
Placental abruption is when the placenta separates from the uterine wall before delivery, which can cause severe bleeding and fetal distress.
Choice C is wrong because it describes a normal position of the placenta at the top of the womb.
This does not interfere with vaginal delivery and does not cause bleeding.
Choice D is wrong because it describes placenta increta or percreta, not placenta previa.
Placenta increta or percreta is when the placenta grows too deeply into or through the uterine wall, which can cause severe bleeding and damage to the uterus and other organs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today