During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.
Which technique should the nurse implement to evaluate the leakage?

Insert a straight urinary catheter to drain the bladder.

Scan the bladder for urinary retention.

Test the fluid with a nitrazine strip.

Palpate the suprapubic area for fetal head position.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Inserting a straight urinary catheter to drain the bladder is not the appropriate technique to evaluate fluid leakage in a pregnant woman. This procedure is invasive and can potentially introduce bacteria into the urinary tract, leading to infection.

Choice B rationale

Scanning the bladder for urinary retention is not the appropriate technique to evaluate fluid leakage in a pregnant woman. While ultrasound can be used to assess the amount of fluid in the bladder, it does not provide information about the nature of the fluid leakage.

Choice C rationale

Testing the fluid with a nitrazine strip is the appropriate technique to evaluate fluid leakage in a pregnant woman. Amniotic fluid has a higher pH than normal vaginal secretions and urine, and will turn a nitrazine strip blue. This test can help determine whether the fluid leakage is amniotic fluid, which could indicate rupture of membranes.

Choice D rationale

Palpating the suprapubic area for fetal head position is not the appropriate technique to evaluate fluid leakage in a pregnant woman. While this can provide information about the position of the fetus, it does not provide information about the nature of the fluid leakage.

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Correct Answer is A

Explanation

Choice A rationale

A client at 32 weeks gestation reporting nausea, vomiting, and elevated blood pressure could be showing signs of a condition called gestational hypertension or preeclampsia. This condition can affect the health of both the mother and the baby, depending on how severe the issue is. Inspecting the client’s face for edema is a relevant next step because swelling in the face, hands, or fingers is a common symptom of preeclampsia.

Choice B rationale

While headaches can be a symptom of preeclampsia, asking about a history of cluster headaches may not be the most immediate concern in this situation. Cluster headaches are a specific type of headache that is not directly related to pregnancy or preeclampsia.

Choice C rationale

Determining the frequency of headaches could be useful in assessing the client’s overall health, but it may not be the most immediate concern when the client is showing potential signs of preeclampsia.

Choice D rationale

Monitoring and timing the client’s contractions would be more relevant if the client was in labor or showing signs of preterm labor. In this case, the client’s symptoms are more indicative of a hypertensive disorder of pregnancy.

A. Measure vital signs. B. Obtain human chorionic gonadotropin levels. C. Collect urine sample for urinalysis. D. Recommend bed rest.

Correct Answer is B

Explanation

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.

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During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

Correct Answer is A

Explanation

The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Correct Answer is B

Explanation

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During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.
Which technique should the nurse implement to evaluate the leakage?