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 A
Explanation
The correct answer is choice A. A 23-year-old primigravida with a history of endometriosis.Endometriosis is a condition where the tissue that normally lines the uterus grows outside of it, sometimes affecting the fallopian tubes.This can cause scarring and damage to the tubes, which can increase the risk of ectopic pregnancy.
Choice B is wrong because condyloma acuminata, also known as genital warts, are caused by human papillomavirus (HPV) infection.HPV infection does not directly increase the risk of ectopic pregnancy, although it may be associated with other sexually transmitted infections (STIs) that can cause pelvic inflammatory disease (PID), which is a risk factor.
Choice C is wrong because a bicornuate uterus is a congenital anomaly where the uterus has two horns or chambers instead of one.This does not affect the fallopian tubes or the implantation of the fertilized egg in the uterus.
Choice D is wrong because previous cesarean deliveries do not increase the risk of ectopic pregnancy.However, previous tubal surgery, such as tubal ligation or salpingectomy, can damage the fallopian tubes and increase the risk.
Other risk factors for ectopic pregnancy include previous ectopic pregnancy, smoking, age older than 35 years, history of infertility, and use of assisted reproductive technology.
Correct Answer is C
Explanation
Answer and explanation..
The correct answer is choice C. Jitteriness.Jitteriness is a sign of low blood sugar (hypoglycemia) which is common in infants of diabetic mothers (IDM) because they have high levels of insulin in their blood that lower their glucose levels after birth.Hypoglycemia can also cause other symptoms such as seizures, lethargy, poor feeding, sweating, trembling, and pale complexion.
Choice A is wrong because abdominal distention is not a typical symptom of IDM.
It can be caused by other conditions such as intestinal obstruction or infection.
Choice B is wrong because high-pitched cry is not a specific symptom of IDM.
It can be caused by many factors such as pain, hunger, or neurological problems.
Choice D is wrong because excessive drooling is not a common symptom of IDM.
It can be a sign of oral problems such as teething or infection.
Normal ranges for blood glucose in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).
IDM should be monitored closely for hypoglycemia and treated promptly with glucose if needed.
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