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 A

Explanation

he correct answer is choice A. “Instead of having eggs, I am eating yogurt for breakfast.” This statement shows a need for further instruction because eggs are a good source of protein and yogurt is not.

Yogurt is a dairy product that contains mostly carbohydrates and some fat.

Eggs are an animal product that contains mostly protein and some fat.

Protein is important for building and repairing tissues in the body.

Choice B is correct because adding powdered milk to skim milk increases the protein content of the drink.

Powdered milk is a dairy product that contains protein, carbohydrates and fat.

Skim milk is a dairy product that contains protein and carbohydrates but no fat.

Choice C is correct because peanut butter is a good source of protein and healthy fats.

Peanut butter is a plant product that contains protein, fat and some carbohydrates.

Crackers are a grain product that contains mostly carbohydrates and some protein.

Choice D is correct because cream of tomato soup is a good source of protein and calories.

Cream of tomato soup is a processed food that contains tomatoes, cream, flour and seasonings.

Tomatoes are a vegetable that contains mostly water and some carbohydrates.

Cream is a dairy product that contains mostly fat and some protein.

Flour is a grain product that contains mostly carbohydrates and some protein.

Seasonings are herbs and spices that contain mostly flavor and some nutrients.

The normal range of protein intake for adults is 0.8 to 1 gram per kilogram of body weight per day.

This means that an adult who weighs 70 kilograms should consume about 56 to 70 grams of protein per day.

A. Document the findings. B. Pause the oxytocin infusion. C. Raise the head of the patient’s bed 30 degrees. D. Notify the health care provider. E. Notify the health care provider.

Correct Answer is B

Explanation

This is because late fetal heart rate decelerations are a sign of uteroplacental insufficiency, which means that the placenta is not delivering enough oxygen and nutrients to the fetus.Oxytocin can cause uterine tachysystole, which is excessive and frequent contractions that reduce blood flow to the placenta.Therefore, stopping the oxytocin infusion can help improve placental perfusion and fetal oxygenation.

Choice A is wrong because documenting the findings is not a priority action in this situation.

The nurse should first intervene to address the cause of late decelerations and then document the actions and outcomes.

Choice C is wrong because raising the head of the patient’s bed 30 degrees does not directly affect the placental blood flow or fetal oxygenation.

It may help with maternal comfort and breathing, but it is not an essential action for late decelerations.

Choice D is wrong because notifying the health care provider is not the first action to take.The nurse should first attempt to correct the cause of late decelerations by pausing the oxytocin infusion and then notify the health care provider if there is no improvement or if there are other signs of fetal distress.

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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

A patient has been instructed to increase the protein in her diet. Which statement by the patient shows a need for further instruction?

Correct Answer is A

Explanation

A patient’s labor is induced using an intravenous infusion of 1,000 mL Ringer’s lactate with 10 units of oxytocin. Two hours later, the nurse notes a pattern of late fetal heart rate decelerations detected on the fetal monitor.Which action is essential for the nurse to take first?

Correct Answer is B

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?