A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hours.
Which of the following diagnostic tests should the nurse anticipate?

Speculum exam to test for fetal fibronectin.

Vaginal swab for nitrazine testing.

Urinalysis to determine protein content.

Amniocentesis to determine fetal lung maturity.

Answer and Explanation

The Correct Answer is B

Choice A rationale

A speculum exam to test for fetal fibronectin is primarily used to predict the risk of preterm labor in symptomatic women between 22 and 34 weeks of gestation. Since the client is at 37 weeks of gestation (term) and the concern is a slow trickle of fluid suggesting rupture of membranes (ROM), this test is not appropriate for the current clinical presentation or gestational age.

Choice B rationale

Nitrazine testing is a rapid, non-invasive method used to determine if the fluid leaking from the vagina is amniotic fluid. Amniotic fluid is alkaline (pH of 7.0 to 7.5) and will turn the yellow-to-orange nitrazine paper to a characteristic deep blue color, which helps confirm the diagnosis of premature rupture of membranes (PROM), a likely cause of the reported fluid trickle.

Choice C rationale

A urinalysis determines components like protein, glucose, and ketones, and is mainly used to screen for conditions such as preeclampsia (indicated by proteinuria) or urinary tract infection (UTI). While part of routine prenatal care, it is not the diagnostic test for confirming ruptured membranes, which is the primary concern given the client's report of a slow trickle of vaginal fluid.

Choice D rationale

Amniocentesis is an invasive procedure used to aspirate amniotic fluid, typically to assess fetal lung maturity (L/S ratio) or for genetic testing. Since the client is at 37 weeks and the suspicion is ruptured membranes, which warrants immediate action due to infection risk, the risks and benefits of an amniocentesis for lung maturity are not justified.

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Correct Answer is C

Explanation

Choice A rationale

Delaying the epidural until the client reaches a specific dilation, such as 7 cm, is not based on current standards of pain management; an epidural can be administered at any time during active labor, as long as the client desires it and there are no contraindications. Labor progress is often enhanced, not hindered, by effective pain relief, which reduces catecholamine release and subsequent uterine vasoconstriction, promoting efficient uterine contractions. The decision to administer an epidural is primarily based on maternal request and clinical assessment.

Choice B rationale

Placing the client in a supine position (lying flat on the back) before epidural placement or during labor is contraindicated because the gravid uterus can compress the vena cava and aorta, reducing venous return and subsequently decreasing cardiac output and uteroplacental perfusion. This supine hypotension syndrome can lead to fetal distress. The client should be positioned on their side or sitting upright with feet supported, or with a wedge under the hip to maintain lateral tilt.

Choice C rationale

Administering an intravenous fluid bolus, typically 500 to 1000 mL of an isotonic solution like Lactated Ringer's or 0.9% Sodium Chloride, is a standard prophylactic measure before epidural anesthesia. This fluid load expands the intravascular volume, which helps to mitigate the common side effect of hypotension caused by the sympathetic blockade resulting from the anesthetic agents diffusing into the epidural space and causing peripheral vasodilation.

Choice D rationale

Ondansetron is an antiemetic used to prevent nausea and vomiting, which can sometimes occur with labor or as a side effect of opioid use or hypotension associated with epidural placement. However, it is not the primary or most immediate action before an epidural, nor is it a universal prophylactic requirement. The priority before an epidural is the IV fluid bolus to prevent hypotension, which poses a greater immediate risk to the mother and fetus.

A. Irritability B. Pupil response C. Milia on nose and cheeks D. Lanugo on bilateral shoulders E. Axillary temperature F. Respiratory rate G. Apical heart rate H. Lung findings I. Stool characteristics J. Abdomen findings

Correct Answer is ["A","E","F"]

Explanation

Body System	Finding	Interpretation	Report to Provider?
Neurologic	Irritability	Can be normal if mild, but persistent irritability may indicate hypoglycemia, hypocalcemia, withdrawal, or infection → concerning	✅ Yes
	Pupil response (brisk, equal)	Normal neuro finding	❌ No
Integumentary	Milia on nose/cheeks	Benign, normal newborn finding	❌ No
	Lanugo on shoulders	Normal in preterm/term newborns	❌ No
Cardiopulmonary	Axillary temperature 36.2°C (97.2°F)	Low temp (normal 36.5–37.5°C). Hypothermia can indicate infection, poor thermoregulation	✅ Yes
	Respiratory rate 80/min	Tachypnea (normal 30–60/min). May indicate respiratory distress, sepsis, metabolic issue	✅ Yes
	Apical heart rate 158/min	Normal (110–160/min)	❌ No
	Lung findings (clear)	Normal	❌ No
Gastrointestinal	Stool characteristics (meconium, normal)	Normal	❌ No
	Abdomen findings (not abnormal)	Normal	❌ No

🧾 Explanation

Irritability: While some fussiness is expected, persistent irritability is a red flag for metabolic or infectious causes.
Temperature 36.2°C: Below normal → newborn hypothermia, which can worsen quickly.
Respiratory rate 80/min: Markedly elevated → tachypnea, possible respiratory distress or sepsis.
Other findings (milia, lanugo, brisk pupils, HR 158, clear lungs, normal stool) are expected newborn variations and do not require reporting.

✅ Final Answer: The nurse should report:

Neurologic: Irritability
Cardiopulmonary: Axillary temperature 36.2°C
Cardiopulmonary: Respiratory rate 80/min

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A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hours. Which of the following diagnostic tests should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and requesting an epidural. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is ["A","E","F"]

Explanation

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A nurse is caring for a client who is at 37 weeks of gestation and reports a slow trickle of vaginal fluid for the past 12 hours.
Which of the following diagnostic tests should the nurse anticipate?