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 D
Explanation
The correct answer is choice D. Placing warmed tea bags on the nipples is not a recommended method to avoid nipple soreness while breastfeeding.Tea bags can cause dryness and cracking of the nipples, which can increase the risk of infection and pain.
Choice A is wrong because it is better to use both breasts at each feeding and switch the starting breast at each feeding.This helps to ensure adequate milk production and drainage.
Choice B is correct because rubbing breast milk into the nipple can help to moisturize and protect the nipple from infection.Breast milk has antibacterial and healing properties.
Choice C is correct because washing the nipples with water but no soap can help to prevent irritation and dryness of the nipples.
Soap can remove the natural oils that protect the skin.Letting the nipples air dry can also help to prevent fungal growth.
Correct Answer is C
Explanation
The correct answer is choice C. Remind the patient that the nurse will stay with her during the examination.
This measure would help reduce the patient’s anxiety by providing emotional support and reassurance.
The patient may feel scared, embarrassed, or vulnerable during the pelvic examination, especially since she is young and pregnant.
Having a trusted person with her can help her cope with these feelings.
Choice A is wrong because it may imply that the examination will be painful and increase the patient’s anxiety.
Choice B is wrong because it may make the patient feel like she is not being treated as an individual and that her concerns are not valid.
Choice D is wrong because it may make the patient feel rushed or pressured and not allow her to ask questions or express her feelings.
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