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 C

Explanation

The correct answer is choice C.Adolescents need more protein than older pregnant women because they are still growing themselves and need to support the growth of the baby and the placenta.Protein can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.

Choice A is wrong because adolescents need more supplemental iron than older women, not less.This is because they have lower iron stores due to rapid growth and menstruation.Iron deficiency can cause anemia and increase the risk of infections and bleeding.Iron can be found in meat, poultry, fish, eggs, dairy products, beans, nuts, and fortified cereals.

Choice B is wrong because adolescents need more carbohydrates than older women, not less.Carbohydrates provide energy for the mother and the baby and spare protein for other functions.Carbohydrates can be found in grains, fruits, vegetables, and dairy products.

Choice D is wrong because adolescents need the same amount of vitamin C as older pregnant women, which is 85 milligrams per day.Vitamin C helps with wound healing, collagen formation, iron absorption, and immune function.Vitamin C can be found in citrus fruits, tomatoes, peppers, broccoli, potatoes, and fortified juices.

A. “Have you had any shortness of breath?”. B. “Have you had any episodes of loss of consciousness?”. C. “Have you had any spotting?”. D. “Have you noticed any tenderness in your breasts?”.

Correct Answer is D

Explanation

The correct answer is choice D. “Have you noticed any tenderness in your breasts?”

Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.

Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.

Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.

Choice C is wrong because spotting is not a sign of early pregnancy.

It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.

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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?

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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?