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 C
Explanation
The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.
Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.
Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.
Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.
Correct Answer is C
Explanation
This is because urine toxicology studies can detect the presence of cocaine and other drugs in the body of the pregnant woman and her unborn baby.Cocaine use during pregnancy can have serious consequences for both the mother and the baby, such as high blood pressure, premature labor, low birth weight, and developmental problems.
Choice A is wrong because urine estriol levels are used to measure the activity of the placenta and the fetal adrenal glands.They are not related to cocaine use.
Choice B is wrong because serum bilirubin levels are used to assess the liver function and the risk of jaundice in newborns.They are not related to cocaine use.
Choice D is wrong because lecithin-sphingomyelin ratio is used to evaluate the fetal lung maturity and the risk of respiratory distress syndrome.It is not related to cocaine use.
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