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

Bright red bleeding in the third trimester of a pregnancy with an Rh-negative mother is an obstetric emergency and warrants the highest priority. The immediate assessment of the fetal heart rate (FHR) and the mother's contraction pattern is crucial. The nurse must determine if the bleeding is caused by conditions such as placental abruption or placenta previa, both of which are life-threatening for the mother and the fetus.

Choice B rationale

While a sterile vaginal examination may eventually be necessary to diagnose the cause of bleeding, it is not the immediate priority. Assessment of fetal well-being and maternal status takes precedence. Additionally, performing a vaginal examination increases the risk of further hemorrhage and potential infection.

Choice C rationale

Leopold maneuvers are used to determine fetal presentation and position, but they are not the priority intervention in this scenario. The nurse's main concern is stabilizing the mother and assessing for signs of fetal distress.

Choice D rationale

Assessing the woman's Rh and Coombs status for RhoGam administration is important. Still, it is not the most immediate priority in this life-threatening situation. The priority is to assess fetal well-being and stabilize the mother. If placental abruption is suspected, RhoGam administration may not be indicated.

Correct Answer is ["50"]

Explanation

To calculate the rate at which the infusion pump should be set, we need to determine how many mL of the solution contain 2 grams of magnesium sulfate.

Step 1: First, we find out how many grams of magnesium sulfate are in 1 mL of the solution. The IV bag contains 20 grams of magnesium sulfate in 500 mL, so we divide 20 grams by 500 mL to get the amount of magnesium sulfate per mL: 20 grams ÷ 500 mL = 0.04 grams/mL

Step 2: Next, we find out how many mL contain 2 grams of magnesium sulfate.

We divide 2 grams by the amount of magnesium sulfate per mL: 2 grams ÷ 0.04 grams/mL = 50 mL Therefore, the nurse should set the infusion pump to deliver 50 mL per hour.

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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

Correct Answer is A

Explanation

Correct Answer is ["50"]

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?