A nurse is caring for a client who is at 16 weeks of gestation and reports a sudden gush of vaginal fluid.
Which of the following findings indicates premature rupture of membranes?
Vaginal fluid has a pH of 5.3.
Nitrazine paper turns dark blue.
Vaginal fluid is negative for ferning.
Nitrazine paper turns yellow.
The Correct Answer is B
Choice A rationale
Vaginal fluid with a pH of 5.3 is acidic and falls within the normal range for vaginal secretions, which are typically between 3.8 and 4.5. Amniotic fluid is alkaline, with a pH of 7.0 to 7.5. Therefore, an acidic pH does not indicate premature rupture of membranes.
Choice B rationale
Nitrazine paper turning dark blue indicates an alkaline pH, which is characteristic of amniotic fluid (pH 7.0-7.5). The presence of alkaline fluid in the vagina suggests premature rupture of membranes, as normal vaginal secretions are acidic.
Choice C rationale
A positive ferning test, where amniotic fluid dries in a fern-like pattern on a microscope slide, indicates the presence of amniotic fluid. A negative ferning test would suggest that the fluid is not amniotic fluid.
Choice D rationale
Nitrazine paper turning yellow indicates an acidic pH, which is consistent with normal vaginal secretions or urine. This finding would suggest that the fluid is not amniotic fluid, as amniotic fluid is alkaline and would turn the paper blue or dark blue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The newborn's fingers curling around the nurse's finger when placed in the palm describes the grasping reflex, also known as the palmar grasp. This is an expected neurological finding in a full-term newborn, indicating intact primitive reflexes and proper neurological development. This reflex typically persists until about 5-6 months of age.
Choice B rationale
The newborn closing their eyes and keeping them closed when tapped on the forehead is not a typical expected reflex. This describes the glabellar reflex, which involves blinking in response to tapping between the eyebrows. However, sustained eye closure without blinking is not a characteristic normal finding, suggesting potential neurological variation.
Choice C rationale
The newborn turning their head away from the stimulus when their cheek is touched is an unexpected finding. The rooting reflex, a normal primitive reflex, involves the newborn turning their head *towards* the stimulus and opening their mouth when the cheek or corner of the mouth is touched. Turning away would suggest an absent or atypical reflex response.
Choice D rationale
The newborn's legs flexing at the knees and hips when pressure is applied to the soles of the newborn's feet is known as the stepping or walking reflex. This reflex involves coordinated leg movements resembling walking. However, the description here is vague; the plantar grasp reflex involves toe curling, and strong, isolated flexion is not typically the sole response.
Correct Answer is ["0.5"]
Explanation
Calculation
400 mg ÷ 800 mg = 0.5 tablets.
The nurse should administer 0.5 tablets with each dose.
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