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 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.
Correct Answer is A
Explanation
The correct answer is choice A. The patient uses the sitz bath three times a day.This indicates that the patient understands the benefits of sitz baths for postpartum recovery, such as pain relief, increased blood flow, relaxation, cleansing, and itch relief.Sitz baths can be done with warm or cool water, depending on the preference of the patient.However, they should not be done for more than 20 minutes at a time, as this can cause the stitches in the perineal area to fall apart.
Therefore, choice C is wrong.Choice B is also wrong, as there is no evidence that alternating between warm and cool sitz baths has any additional benefits or effects.
Choice D is wrong, as tightening and relaxing the perineal muscles during a sitz bath is not recommended.This can cause more pain and irritation to the area, and interfere with the healing process.The normal ranges for sitz baths are two to four times a day for up to 20 minutes each.
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