A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control.
Findings of the last vaginal exam, performed one hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station.
Which action should the nurse implement first?

1. Blood pressure: 170/98 mm Hg: Abnormal. A blood pressure reading of 170/98 mm Hg is high, especially in the context of pregnancy, where it may indicate gestational hypertension or the potential for preeclampsia. This needs to be monitored closely.
2. Pain rating: 5/10 with contractions: Normal. A pain rating of 5/10 is typical during labor, especially at this stage of dilation (4 cm). Pain management can be adjusted based on the client's preference and progress.
3. Variable decelerations: 20 seconds: Normal. Occasional variable decelerations (drops in fetal heart rate that last for less than 30 seconds) can occur during labor, often due to umbilical cord compression. As long as the decelerations are brief and not repetitive or severe, they are typically not concerning.
4. Magnesium sulfate infusion ongoing: Normal. The magnesium sulfate infusion is prescribed to manage potential complications, likely to prevent preterm labor or to prevent seizures in the event of preeclampsia. Its ongoing use is appropriate for this client at this stage.

Choice A rationale

Palpating the suprapubic area to assess fetal head position is not relevant to identifying the source of fluid leakage. This technique is used to evaluate fetal engagement in the pelvis, particularly near term, but it does not help in determining whether the fluid leakage is amniotic fluid or urine.

Choice B rationale

Scanning the bladder for urinary retention is unrelated to identifying the nature of fluid leakage. A bladder scan is useful for detecting residual urine volume in the bladder, often post-voiding, and is typically used in cases of urinary retention or post-operative care.

Choice C rationale

Testing the fluid with a nitrazine strip is a standard method to distinguish amniotic fluid from urine or vaginal secretions. Amniotic fluid has a higher pH (usually between 7.0 and 7.5), causing the nitrazine strip to turn blue, whereas urine and vaginal secretions usually have a lower pH, resulting in a yellow or green color on the strip.

Choice D rationale

Inserting a straight urinary catheter to drain the bladder is an invasive procedure that does not directly identify the source of fluid leakage. This technique is typically used to relieve urinary retention or to collect a sterile urine specimen, not for diagnosing amniotic fluid leakage.