Nokea
When the nurse performs the Nitrazine test on vaginal secretions of a patient who thinks her membranes have ruptured the paper turns yellow. What does this finding indicate?
- A. Acidic discharge membranes intact
- B. Acidic discharge membranes have ruptured
- C. Neutral not enough discharge to measure
- D. Alkaline membranes have ruptured
Correct Answer: A
Rationale: When the Nitrazine paper turns yellow it is indicative of acidic discharge, meaning the membranes are intact. Amniotic fluid is alkaline and turns the paper blue.
You may also like to solve these questions
The nurse is alarmed as she assesses a protruding umbilical cord from the vagina. What immediate action should the nurse take?
- A. Monitor intensity of contractions.
- B. Place the patient in the knee-chest position.
- C. Notify the charge nurse.
- D. Ask the patient to perform a Valsalva's maneuver.
Correct Answer: B
Rationale: The knee-chest position reduces the pressure on the prolapsed cord. The charge nurse will need to be notified, and the contractions will need to be monitored. However, the priority is reducing the pressure on the prolapsed cord.
The nurse explains to the patient whose membranes ruptured an hour ago that delivery is usually accomplished in ___ to 24 hours postrupture.
Correct Answer: 18
Rationale: After the rupture of membranes, labor is usually accomplished in 18 to 24 hours.
For the first hour following delivery how often should the nurse assess the mother?
- A. Every 5 minutes
- B. Every 10 minutes
- C. Every 15 minutes
- D. Every 30 minutes
Correct Answer: C
Rationale: During the first hour, assessments are done every 15 minutes.
The patient's membranes have just ruptured. What is the first priority of the nurse?
- A. Turn the patient on the left side.
- B. Perform a Nitrazine test.
- C. Check the fetal heart rate (FHR).
- D. Perform a vaginal examination.
Correct Answer: C
Rationale: The FHR should be assessed immediately after rupture of the membranes to determine the well-being of the baby.
What area of the uterus provides the force during a contraction?
- A. Lower portion
- B. Middle portion
- C. Upper portion
- D. Cervical portion
Correct Answer: C
Rationale: The upper portion of the uterus provides the force during contractions.