During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.
Which technique should the nurse implement to evaluate the leakage?

Insert a straight urinary catheter to drain the bladder.

Scan the bladder for urinary retention.

Test the fluid with a nitrazine strip.

Palpate the suprapubic area for fetal head position.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Inserting a straight urinary catheter to drain the bladder is not the appropriate technique to evaluate fluid leakage in a pregnant woman. This procedure is invasive and can potentially introduce bacteria into the urinary tract, leading to infection.

Choice B rationale

Scanning the bladder for urinary retention is not the appropriate technique to evaluate fluid leakage in a pregnant woman. While ultrasound can be used to assess the amount of fluid in the bladder, it does not provide information about the nature of the fluid leakage.

Choice C rationale

Testing the fluid with a nitrazine strip is the appropriate technique to evaluate fluid leakage in a pregnant woman. Amniotic fluid has a higher pH than normal vaginal secretions and urine, and will turn a nitrazine strip blue. This test can help determine whether the fluid leakage is amniotic fluid, which could indicate rupture of membranes.

Choice D rationale

Palpating the suprapubic area for fetal head position is not the appropriate technique to evaluate fluid leakage in a pregnant woman. While this can provide information about the position of the fetus, it does not provide information about the nature of the fluid leakage.

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Correct Answer is B

Explanation

Choice A rationale

While hard, painful uterine afterpains can be uncomfortable for the patient, they are a normal part of the postpartum period and are not typically a priority complication following a severe postpartum hemorrhage16.

Choice B rationale

Disseminated intravascular coagulation (DIC) is a serious condition that can occur as a complication of severe postpartum hemorrhage. It involves an overactive clotting process leading to the formation of small blood clots that can block blood vessels and cause significant organ damage16.

Choice C rationale

Postpartum psychosis is a serious mental health disorder that can occur after childbirth. However, it is not directly related to postpartum hemorrhage and would not typically be the priority complication in this scenario16.

Choice D rationale

Placenta accreta is a condition where the placenta grows too deeply into the uterine wall. While it can cause severe bleeding after delivery, it would not typically be a priority complication to assess for following a severe postpartum hemorrhage16.

A. Nausea and vomiting. B. Fluid volume excess. C. Sleep deprivation. D. Risk for infection.

Correct Answer is B

Explanation

Choice A rationale

While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.

Choice B rationale

Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.

Choice C rationale

While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.

Choice D rationale

While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.

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During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.
Which technique should the nurse implement to evaluate the leakage?