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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is []

Explanation

Rationale for correct condition Endometritis is a postpartum uterine infection, often following cesarean birth and prolonged rupture of membranes. It presents with a boggy, tender uterus, foul-smelling lochia, fever or chills, and malaise. This client’s symptoms—uterine tenderness, foul lochia, and systemic signs—are classic for endometritis. Bottle-feeding increases risk due to lack of uterine oxytocin stimulation. Early recognition is critical to prevent sepsis.

Rationale for correct actions Oxytocin promotes uterine contractions, aiding involution and reducing bacterial proliferation in retained lochia. A firm uterus also minimizes bleeding. Broad-spectrum antibiotics target polymicrobial pathogens common in endometritis, including Escherichia coli and anaerobes. Prompt antibiotic therapy reduces systemic spread and improves recovery.

Rationale for correct parameters Lochia characteristics reflect uterine healing; foul odor and increased volume suggest ongoing infection. Monitoring changes helps evaluate treatment response. Temperature is a key systemic marker of infection; decreasing fever indicates therapeutic effectiveness. Persistent fever may signal treatment failure or complications.

Rationale for incorrect conditions Urinary tract infection typically presents with dysuria, urgency, and suprapubic pain—not uterine tenderness or foul lochia. Deep vein thrombosis involves unilateral leg pain, swelling, and warmth, which are absent here. Engorgement causes breast discomfort, not systemic symptoms or uterine findings.

Rationale for incorrect actions Increased fluid intake supports general health but does not directly treat endometritis. Anticoagulants are used for thrombosis, not uterine infection. Ice packs relieve breast engorgement but are unrelated to uterine infection management.

Rationale for incorrect parameters Leg circumference is relevant for DVT, not uterine infection. Nipple integrity is important for breastfeeding issues, not applicable here. Bladder distention is not contributing to uterine tenderness or infection in this case.

Take home points

Endometritis is a common postpartum infection, especially after cesarean birth and prolonged rupture of membranes.
Key signs include uterine tenderness, foul-smelling lochia, and systemic symptoms like fever or chills.
Management includes uterotonic agents and broad-spectrum antibiotics.
Differentiate from UTI, DVT, and breast engorgement based on localized versus systemic findings.

A. Cry characteristics B. Nasal findings C. Tremor D. Maternal urine drug screen E. Respiratory rate

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

? Rationales for Each Condition

1️⃣ Neonatal abstinence syndrome (NAS)

Definition: NAS is a withdrawal syndrome in newborns caused by in utero exposure to opioids or other substances. It typically presents within 24–72 hours after birth.

Findings and Scientific Explanation:

Cry characteristics: A high-pitched, inconsolable cry is a hallmark of NAS due to autonomic nervous system dysregulation.
Nasal findings: Sneezing and nasal stuffiness are common due to increased autonomic activity and are not typically seen in hypoglycemia.
Tremor: Tremors, especially when undisturbed, are due to central nervous system irritability from opioid withdrawal.
Maternal urine drug screen: A positive result for opioids confirms in utero exposure, supporting a diagnosis of NAS.
Respiratory rate: Tachypnea (e.g., 65/min on Day 3) is common in NAS due to increased metabolic demand and autonomic instability. Normal neonatal respiratory rate is 30–60/min.

2️⃣ Hypoglycemia

Definition: Neonatal hypoglycemia is defined as a plasma glucose concentration less than 40–45 mg/dL in the first 24 hours of life.

Findings and Scientific Explanation:

Cry characteristics: Hypoglycemia may cause irritability or weak cry due to neuroglycopenia.
Tremor: Tremors or jitteriness can result from adrenergic stimulation in response to low glucose levels.
Respiratory rate: Tachypnea may occur as a compensatory response to metabolic acidosis secondary to hypoglycemia. The newborn had a glucose of 35 mg/dL on Day 1, which is below the normal range (>40–45 mg/dL).

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

A nurse is planning to reinforce nutritional teaching with a client who is in her first trimester of pregnancy. The nurse should recommend an increase in which of the following nutrients to support an increase in maternal blood volume during pregnancy?

A nurse is collecting data from a newborn who is 4 hours old. Which of the following findings should the nurse report to the provider?

A nurse on the labor and delivery unit is assisting in the care of a newborn at 1 hour old. Exhibits The nurse reinforces teaching regarding newborn hypoglycemia. Which of the following client statements indicate understanding of newborn hypoglycemia? Select all that apply.

A nurse is collecting data from an adolescent who is postoperative following a cesarean birth and is receiving morphine for pain. Which of the following findings is the nurse's priority?

A nurse at a provider’s office is caring for a 24-year-old female client. Exhibits Complete the following sentence by using the lists of options. The nurse should prepare to reinforce teaching with the client about a dropdown with a prescription of dropdown.

A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron. Which of the following foods should the nurse recommend as the best source of iron?

A nurse is assisting in the care of a client in the intrapartum unit. Exhibits Which of the following actions should the nurse take? Select all that apply.

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?