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. Orange juice.This is because orange juice is rich in vitamin C, which enhances the absorption of iron from ferrous sulfate tablets.Vitamin C helps reduce iron to its ferrous form, which is more readily absorbed by the intestinal cells.
Choice A is wrong because milk contains calcium, which inhibits iron absorption by forming insoluble complexes with iron.Choice
B is wrong because tea contains tannins, which are polyphenols that bind to iron and decrease its bioavailability.Choice C is wrong because water does not have any effect on iron absorption, neither enhancing nor inhibiting it.
Normal ranges for serum iron are 50-170 mcg/dL for men and 40-150 mcg/dL for women.Normal ranges for hemoglobin are 13.5-17.5 g/dL for men and 12-15.5 g/dL for women.
Correct Answer is D
Explanation
The correct answer is choice D. Rest on your side as much as possible.This is because resting on the side can improve blood flow to the placenta and lower blood pressure.It can also reduce the risk of supine hypotensive syndrome, which occurs when the weight of the uterus compresses the inferior vena cava and reduces venous return.
Choice A is wrong because spicy foods have no effect on blood pressure or pregnancy outcomes.Choice B is wrong because limiting fluid intake can lead to dehydration and increase blood viscosity, which can worsen hypertension.Choice C is wrong because urinating frequently does not lower blood pressure or prevent complications of pregnancy-induced hypertension.
Pregnancy-induced hypertension (PIH) is a condition that causes high blood pressure during pregnancy.It can lead to serious problems for both the mother and the baby, such as pre-eclampsia, eclampsia, placental abruption, fetal growth restriction, and stillbirth.
Women with PIH should follow their doctor’s advice on medication, diet, exercise, and monitoring.They should also report any symptoms of pre-eclampsia, such as severe headache, blurred vision, abdominal pain, or swelling.
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