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 A
The correct answer is choice B. Test the patient’s vaginal secretions with nitrazine paper.
This is because the patient may be leaking amniotic fluid rather than urine, and nitrazine paper can help differentiate between the two by testing the pH level. Amniotic fluid is alkaline and will turn the paper blue, while urine is acidic and will turn the paper yellow.
Choice A is wrong because checking the patient’s bladder for distention will not help determine if the patient is leaking amniotic fluid or urine.
Choice C is wrong because checking the patient’s urine for glucose content will not help determine if the patient is leaking amniotic fluid or urine.
Glucose content may be elevated in patients with gestational diabetes, but this is not related to the patient’s complaint.
Choice D is wrong because obtaining a specimen of the patient’s vaginal secretions for culture will not help determine if the patient is leaking amniotic fluid or urine.
Culture may be done to check for infections, but this is not the initial action that the nurse should take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Dry off the newborn.This is the priority nursing action because it prevents heat loss and hypothermia in the newborn.
The newborn has a large surface area and a thin layer of subcutaneous fat, making it vulnerable to cold stress.Drying off the newborn also stimulates breathing and crying, which helps clear the airways.
Choice A is wrong because obtaining a serum sample is not a priority action and may cause unnecessary pain and bleeding in the newborn.
Choice C is wrong because assessing the newborn’s Moro reflex is not a priority action and may be done later during the physical examination.Choice D is wrong because obtaining the newborn’s footprints is not a priority action and may be done after the bonding and breastfeeding period.
Correct Answer is A
Explanation
he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.
Yogurt is a dairy product that contains mostly carbohydrates and some fat.
Eggs are an animal product that contains mostly protein and some fat.
Protein is important for building and repairing tissues in the body.
Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.
Powdered milk is a dairy product that contains protein, carbohydrates and fat.
Skim milk is a dairy product that contains protein and carbohydrates but no fat.
Choice C is correct because peanut butter is a good source of protein and healthy fats.
Peanut butter is a plant product that contains protein, fat and some carbohydrates.
Crackers are a grain product that contains mostly carbohydrates and some protein.
Choice D is correct because cream of tomato soup is a good source of protein and calories.
Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.
Tomatoes are a vegetable that contains mostly water and some carbohydrates.
Cream is a dairy product that contains mostly fat and some protein.
Flour is a grain product that contains mostly carbohydrates and some protein.
Seasonings are herbs and spices that contain mostly flavor and some nutrients.
The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.
This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.
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