A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client’s Glasgow coma scale rating is 15.
Which of the following findings should the nurse expect?

This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.
Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment.
Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection.
Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.
Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:
• Color: pale yellow to amber
• Clarity: clear or slightly cloudy
• Odor: faint aromatic
• pH: 4.5 to 8.0
• Specific gravity: 1.005 to 1.030
• Protein: <150 mg/24 hr
• Glucose: negative
• Ketones: negative
• Blood: negative
• Nitrites: negative
• Leukocyte esterase: negative
• Bacteria: <10,000 CFU/mL

Preterm pre-labor rupture of membranes (PROM) is the spontaneous rupture of the amniotic sac before the onset of labor in a pregnancy less than 37 weeks gestation. It can lead to

infection, cord prolapse, placental abruption, and preterm delivery. The client has risk factors for PROM such as a history of preterm birth and a current infection indicated by fever.

Sepsis is a life-threatening condition that occurs when the body’s response to an infection causes damage to its own tissues and organs. The client has signs of sepsis such as fever, tachycardia, and possible organ dysfunction. The client may have a urinary tract infection, a common cause of sepsis in pregnancy, or an intrauterine infection due to PROM or other factors.

Preeclampsia is not a likely complication for this client because she does not have high blood pressure or proteinuria, which are the defining features of preeclampsia. Seizures are not a likely complication for this client because she does not have epilepsy or eclampsia, which are the leading causes of seizures in pregnancy. Placenta previa is not a likely complication for this client because she does not have painless vaginal bleeding, which is the hallmark symptom of placenta previa.