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. The increase in maternal blood volume is greater than the increase in maternal red blood cells.
This means that the concentration of hemoglobin and hematocrit in the blood is diluted by the extra fluid.
This is a normal physiological adaptation to pregnancy and does not indicate iron deficiency anemia.
Choice A is wrong because placental hormones do not chelate maternal iron.
Chelation is a process of binding metal ions to organic molecules, which is not relevant to this question.
Choice B is wrong because fetal demand for iron is not greater than maternal intake.
The mother can meet the iron needs of the fetus by increasing her dietary intake and taking iron supplements.
Choice C is wrong because maternal intestinal absorption of iron is not decreased during pregnancy.
In fact, it may be increased due to higher levels of estrogen and progesterone.
Correct Answer is A
No explanation
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