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

Answer and Explanation

The Correct Answer is A

The correct answer is choice B. Test the patient’s vaginal secretions with nitrazine paper.

Nitrazine Paper pH on Amniotic Fluid - ppt video online download

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.

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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.

A. To minimize the patient’s oxygen needs. B. To facilitate the conversion of glucose to lactic acid. C. To decrease the absorption of surfactant from the alveoli. D. To increase the patient’s ability to metabolize brown fat stores.

Correct Answer is A

Explanation

The correct answer is choice A: To minimize the patient’s oxygen needs.

Thermal care of the neonate

A neutral thermal environment is an environment in which a neonate maintains a normal body temperature while minimizing energy expenditure and oxygen consumption.This is important for the wellbeing of neonates, especially those who are preterm or have respiratory insufficiency.

Choice B is wrong because the conversion of glucose to lactic acid is not a desired outcome of a neutral thermal environment.This conversion occurs when there is inadequate oxygen supply to the tissues, resulting in anaerobic metabolism and metabolic acidosis.

Choice C is wrong because the absorption of surfactant from the alveoli is not affected by a neutral thermal environment.

Surfactant is a substance that reduces surface tension and prevents alveolar collapse.It is produced by type II alveolar cells and secreted into the alveoli.

Choice D is wrong because the metabolism of brown fat stores is not a desired outcome of a neutral thermal environment.

Brown fat is a specialized tissue that generates heat by nonshivering thermogenesis in response to cold stress.

It is located in the nape of the neck, between the scapulae, and around the kidneys and adrenals.It increases the metabolic rate and oxygen consumption of neonates.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newborn develops hyperbilirubinemia when 24 hours old and is prescribed phototherapy. Which measure is an important part of this newborn’s care plan?

Correct Answer is D

Explanation

A nurse is caring for a newborn who is placed in a neutral thermal environment.What is the desired outcome of this measure?

Correct Answer is A

Explanation

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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?