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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: “This test is used to identify fetal abnormalities.” Alpha-fetoprotein (AFP) is a protein produced by the fetus that can be measured in the mother’s blood.
Abnormal levels of AFP may indicate a problem with the development of the baby’s brain, spine, or other organs.
This test is usually done between 15 and 20 weeks of gestation.
Choice A is wrong because AFP does not measure the baby’s maturity.
It is not related to the gestational age or the lung development of the fetus.
Choice B is wrong because AFP is not a routine test for all pregnant women over thirty years of age.
It is an optional screening test that may be offered to women who have a higher risk of having a baby with a birth defect, such as those who have a family history, a previous affected pregnancy, or certain ethnic backgrounds.
Choice C is wrong because AFP is not recommended for people with a history of infertility.
It does not assess the fertility status of the mother or the father.
It only measures the level of a fetal protein in the mother’s blood.
Correct Answer is D
Explanation
The correct answer is choice D. Gestational age of 35-38 weeks.
This is because preterm babies are more likely to develop jaundice due to their immature liver and increased breakdown of red blood cells.Babies born between 35 and 38 weeks are considered late preterm and have a higher risk of jaundice than full-term babies.
Choice A is wrong because African American ethnicity is not a risk factor for jaundice.In fact, Asian, European, or native American ethnicity are more associated with jaundice.
Choice B is wrong because meconium-stained amniotic fluid is not a risk factor for jaundice.
Meconium is the first stool of the baby and it may indicate fetal distress, but it does not affect the bilirubin level.
Choice C is wrong because bottle feeding is not a risk factor for jaundice.In fact, breastfeeding is more associated with jaundice due to dehydration and poor caloric intake.
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