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
he correct answer is choice D. Keep the infant well hydrated.This is because phototherapy can cause dehydration due to increased insensible water loss from the skin.Hydration helps the infant excrete bilirubin in urine and stool.
Choice A is wrong because elevating the head of the infant’s crib does not affect bilirubin levels or phototherapy effectiveness.
Choice B is wrong because applying a water-soluble ointment to the infant’s eyes can interfere with eye protection and cause eye irritation.The infant’s eyes should be covered with opaque patches or goggles during phototherapy to prevent eye damage.
Choice C is wrong because dressing the infant in a long-sleeved shirt reduces the amount of skin exposed to light and decreases the efficacy of phototherapy.The infant should be undressed except for a diaper and eye protection during phototherapy.
Normal ranges for bilirubin levels vary depending on the age of the infant, the type of jaundice, and the method of measurement.Generally, bilirubin levels above 25 mg/dL are considered dangerous and require urgent treatment.
Correct Answer is B
Explanation
The correct answer is choice B. The administration route of terbutaline will be changed from intravenous to oral.
This is because terbutaline is a medication that can be used to suppress preterm labor by relaxing the uterine smooth muscle.It can be given subcutaneously or intravenously for acute episodes of preterm labor, but it is not recommended for long-term use due to the risk of serious maternal and fetal adverse effects.Therefore, if the client’s condition stabilizes, the administration route of terbutaline will be changed from intravenous to oral, which has a lower bioavailability and less systemic effects.
Choice A is wrong because terbutaline is not usually self-administered parenterally by the client at home.It requires a trained health professional to give it as a shot under the skin or through a vein.
Choice C is wrong because the client does not need to remain in a private room without visitors until she has been without contractions for 48 hours.
This is an unnecessary restriction that may increase the client’s stress and anxiety.
The client should be encouraged to have social support and emotional comfort during this time.
Choice D is wrong because the client should not ambulate in the hallway after 12 hours without contractions.
This may stimulate uterine activity and cause a recurrence of preterm labor.
The client should follow the provider’s instructions on bed rest and activity limitations.
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