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

Answer and Explanation

The Correct Answer is A

The correct answer is choice B. Test the patient’s vaginal secretions with nitrazine paper.

Nitrazine Paper pH on Amniotic Fluid - ppt video online download

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.

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Correct Answer is C

Explanation

The correct answer is choice C. Empty your bladder prior to the test.This is because a full bladder can interfere with the insertion of the needle and increase the risk of complications.Amniocentesis is a test that involves removing and testing a small sample of cells from amniotic fluid, the fluid that surrounds the baby in the womb.It is done to check for genetic or chromosomal conditions, such as Down’s syndrome, Edwards’ syndrome or Patau’s syndrome.

Choice A is wrong because there is no need to remain flat in bed for six hours after the test.You can resume your normal activities after a few hours of rest.

Choice B is wrong because vaginal bleeding is not a normal outcome of amniocentesis.If you experience any bleeding, leaking of fluid, fever or severe pain after the test, you should contact your doctor immediately.

Choice D is wrong because there is no restriction on eating before the test.You can have your normal meals and drinks before amniocentesis.

A. “Have you had any shortness of breath?”. B. “Have you had any episodes of loss of consciousness?”. C. “Have you had any spotting?”. D. “Have you noticed any tenderness in your breasts?”.

Correct Answer is D

Explanation

The correct answer is choice D. “Have you noticed any tenderness in your breasts?”

Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.

Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.

Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.

Choice C is wrong because spotting is not a sign of early pregnancy.

It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?