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 B

Explanation

Choice A rationale

Poor appetite can be a symptom of many neonatal conditions, but it's not the most common complication specifically associated with cephalhematoma.

Choice B rationale

Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.

Choice C rationale

Hypoglycemia is a potential concern in neonates but is not directly related to cephalhematoma.

Choice D rationale

While brain damage is a serious potential complication in cases of severe skull trauma, it's not typically associated with cephalhematoma alone. Cephalhematomas usually resolve on their own without long-term consequences.

A. Initiate phototherapy for the newborn. B. Review the mother’s medical records for blood type and Rh factor. C. Measure bilirubin levels using transcutaneous bilirubinometry. D. Evaluate the results of the cord blood Coomb’s test.

Correct Answer is C

Explanation

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

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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 neonate, who is one day old, develops a cephalhematoma.Which common complication should the nurse assess this neonate for?

Correct Answer is B

Explanation

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

Correct Answer is C

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?