The nurse is admitting a client to labor and delivery who states that her membranes have ruptured. What approach would be best for the nurse to use when assessing for ruptured membranes in a patient?
Obtain a slide sample of vaginal fluid and look for fluid
Test the vaginal fluid with Dextrostix
Perform a VE during a contraction
Test the vaginal fluid with Nitrizine paper
The Correct Answer is D
A. Obtain a slide sample and look for fluid:
May help but less reliable unless seeing ferning under microscope.
B. Test the vaginal fluid with Dextrostix:
Dextrostix checks for glucose, not amniotic fluid.
C. Perform a VE during contraction:
Increases risk of infection, especially if ROM is suspected.
D. Test vaginal fluid with Nitrazine paper:
Nitrazine paper checks pH; amniotic fluid is alkaline and turns the paper blue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. At the end of the active stage
The active stage is part of stage 1, before full dilation.
B. During the latent phase
Too early; cervix not fully dilated.
C. During the 1st stage
Pushing should not occur before complete dilation (end of stage 1).
D. At the beginning of the 2nd stage
The second stage begins at 10 cm dilation- appropriate for pushing.
Correct Answer is D
Explanation
A. Pregnancy induced HTN: Not directly caused by increased blood volume; it's a separate pathologic condition.
B. Rise in BP: BP typically decreases in early pregnancy due to vasodilation.
C. Increased risk of DVT: Caused by hypercoagulable state, not solely by blood volume.
D. Physiologic anemia of pregnancy: Plasma volume increases more than RBC mass, diluting hemoglobin.
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