A client at 37-weeks, 1-day gestation by a 10-week ultrasound, presents to labor and delivery with contractions every 3 to 4 minutes for the last 2 hours.The vaginal exam shows the client is 4 cm dilated, 50% effaced, -3 station.
The membranes are intact.
Contractions occur every 3 to 4 minutes per monitor, lasting 60 seconds, moderate by palpation.
Fetal heart rate is 136 beats/minute with accelerations noted; no decelerations are noted.
The estimated fetal weight by Leopold's is 6 pounds (2.72 kg). The prenatal course is unremarkable, with normal labs.
The client's blood type is A-. An Rh(D) immune globulin injection was received at 28-weeks.

 

Choice A rationale

A respiratory rate of 50 breaths per minute is within the normal range for a newborn and does not indicate respiratory distress. Newborns typically have a higher respiratory rate than adults, and this is considered normal.

Choice B rationale

Shallow and irregular respirations can occur in healthy newborns and do not necessarily indicate respiratory distress. It is important to monitor for additional signs of distress before making a definitive assessment.

Choice C rationale

Flaring of the nares is a sign of respiratory distress in newborns as it indicates increased effort to breathe. This symptom is associated with conditions such as respiratory distress syndrome and requires prompt medical evaluation and intervention.

Choice D rationale

Abdominal breathing with synchronous chest movement is normal for newborns as their diaphragm is the primary muscle for respiration. This type of breathing pattern does not indicate respiratory distress and is expected in healthy newborns.

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.