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 B

Choice A reason: Checking for bladder distention is a secondary nursing assessment to ensure the fetal head can descend properly. However, it does not address the patient's report of leaking fluid. While important for comfort and progress, it lacks the diagnostic priority required to differentiate between urine and amniotic fluid during labor admission.

Choice B reason: This is the priority action to confirm Spontaneous Rupture of Membranes (SROM). Nitrazine paper detects the alkaline pH of amniotic fluid, which turns the paper blue. According to NIH clinical guidelines, distinguishing amniotic fluid from acidic urine is essential to manage infection risks and plan appropriate obstetric interventions for labor.

Choice C reason: Testing for glucose is a metabolic screening tool used to monitor for gestational diabetes or renal threshold changes. It provides no clinical value in determining the status of the amniotic membranes. Following Maslow’s Hierarchy, ensuring physiological safety via membrane assessment takes precedence over routine metabolic urine screenings.

Choice D reason: Obtaining a culture is a diagnostic step for identifying pathogens like Group B Streptococcus, but it is not an initial assessment. Cultures require significant time for results and do not confirm rupture. Rapid bedside tests are the standard initial action to determine if the "bag of water" is broken.

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Correct Answer is D

Explanation

The correct answer is choice D. Cesarean delivery.A pregnant patient with genital herpes is at higher risk of transmitting the infection to the baby during vaginal delivery, especially if there is an active outbreak near the time of birth.This can cause serious complications for the baby, such as brain damage, eye problems, or even death.Therefore, a cesarean delivery is recommended to avoid contact between the baby and the genital lesions.

Choice A is wrong because forceps-assisted second stage of labor is not a complication of genital herpes.

It is a method of assisted delivery that may be used for various reasons, such as fetal distress, maternal exhaustion, or abnormal presentation.

Choice B is wrong because precipitous delivery, which means a very fast labor and delivery, is not a complication of genital herpes.

It may be caused by factors such as multiparity, strong contractions, or previous rapid deliveries.

Choice C is wrong because prolonged first phase of labor, which means a slow dilation of the cervix, is not a complication of genital herpes.

It may be caused by factors such as ineffective contractions, large fetal size, or malposition.

A. “Did you know that your baby’s development is affected by the type of drugs you use during the pregnancy?”. B. “Are you aware that using nonprescription medication during pregnancy may be regarded as child abuse?”. C. “What drugs have you used during your pregnancy?”. D. “Have you ever used street drugs?”.

Correct Answer is C

Explanation

The correct answer is choice C. “What drugs have you used during your pregnancy?”.

This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.

The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.

Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.

Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.

Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.

It also labels the patient as a drug user, which may offend her or make her feel ashamed.

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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

When a pregnant patient has genital herpes, for which complication is the patient at higher risk than the general population?

Correct Answer is D

Explanation

The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?

Correct Answer is C

Explanation

A patient has decided to bottle-feed her twins.The nurse should give this patient which instruction to help alleviate breast engorgement?

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A client who is twO weeks postpartum calls the office and tells a nurse, "l am havinga small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?

A client who is two weeks postpartum calls the office and tells a nurse, "l am having a small amount of brownish discharge from my vagina." Which response is appropriate for the nurse to make?

A patient comes to the family planning clinic requesting information.Which information should the nurse obtain initially to determine the patient’s knowledge base?.

The nurse instructs a class of postpartum women on methods to avoid nipple soreness while breastfeeding. Which comment by a class participant indicates the need for further instruction?

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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?