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 D
Explanation
This is based on the fact that HIV is a virus that attacks the body’s immune system and is spread through certain body fluids, including breast milk.Perinatal transmission can occur during pregnancy, birth, or breastfeeding.Treatment for HIV (antiretroviral therapy, or ART) substantially reduces the risk of perinatal transmission.
Choice A is wrong because sterilizing breast milk does not kill the HIV virus.
Choice B is wrong because colostrum can also contain the HIV virus and testing it is not feasible or reliable.
Choice C is wrong because breastfeeding may still pose a risk of HIV transmission even if the infant is determined to be HIV positive.
The current recommendation in the United States supports shared decision-making between mothers and their healthcare providers regarding infant feeding.Mothers who have questions about breastfeeding or who want to breastfeed should receive patient-centered, evidence-based counseling on infant feeding options, allowing for shared decision-making.
Counseling should begin before conception, or as early as possible in pregnancy and should be
Correct Answer is C
Explanation
A nonstress test (NST) is a test in pregnancy that measures fetal heart rate and reaction to movement.Your pregnancy care provider performs a nonstress test to make sure the fetus is healthy and getting enough oxygen.It’s safe and painless, and gets its name because it puts no stress (nonstress) on you or the fetus.
Choice A is wrong because a nonstress test does not measure the mother’s ability to tolerate the discomfort of labor.A stress test is a different procedure that involves stimulating contractions and monitoring how the fetus responds.
Choice B is wrong because a nonstress test does not measure fetal lie, which is the position of the fetus in the uterus.
Fetal lie is usually determined by ultrasound or physical examination.
Choice D is wrong because a nonstress test does not measure maternal readiness for labor.A nonstress test typically happens after 28 weeks of pregnancy, when fetal heart rate starts reacting to movements.
Maternal readiness for labor is assessed by other factors, such as cervical dilation and effacement.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.