Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which technique should the nurse implement to evaluate the leakage?
A. Insert a straight urinary catheter to drain the bladder.
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.
B. Scan the bladder for urinary retention.
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.
C. Test the fluid with a nitrazine strip.
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.
D. Palpate the suprapubic area for fetal head position.
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.
This question is an excerpt from Nurse Dive's nursing test bank - Care Hope College RN HESI Maternity Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some “heart damage”. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period.
Based on this client’s history, which nursing problem has the highest priority?
A. Nausea and vomiting.
While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.
B. Fluid volume excess.
Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.
C. Sleep deprivation.
While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.
D. Risk for infection.
While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.
Full Explanation
Choice A rationale
While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.
Choice B rationale
Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.
Choice C rationale
While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.
Choice D rationale
While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant’s eyes. He asks the nurse what is the purpose of the ointment.
The nurse would be correct in stating that the purpose for using the ointment is to:
A. Clear the infant’s vision.
The eye ointment used in newborns is not intended to clear the infant’s vision.
B. Dilate the pupil so the red reflex can be visualized.
The purpose of the eye ointment is not to dilate the pupil for visualization of the red reflex.
C. Prevent herpes infection.
While the ointment does help prevent infections, it is not specifically targeted against herpes.
D. Prevent eye infections.
The primary purpose of the eye ointment is to prevent eye infections in newborns. This is particularly important as mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)1.
Full Explanation
Choice A rationale
The eye ointment used in newborns is not intended to clear the infant’s vision.
Choice B rationale
The purpose of the eye ointment is not to dilate the pupil for visualization of the red reflex.
Choice C rationale
While the ointment does help prevent infections, it is not specifically targeted against herpes.
Choice D rationale
The primary purpose of the eye ointment is to prevent eye infections in newborns. This is particularly important as mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)1.
What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?
A. Remind her to push three times with each contraction.
While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
B. Assessing the strength of uterine contractions.
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
C. Re-evaluate the need for medication.
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
D. Assisting her to maintain control.
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.
Full Explanation
Choice A rationale
While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.
Choice B rationale
Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.
Choice C rationale
Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.
Choice D rationale
Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.