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
Elevated maternal serum alpha-fetoprotein (MSAFP) levels are highly suggestive of neural tube defects (NTDs) such as spina bifida and anencephaly. Alpha-fetoprotein (AFP) is a glycoprotein produced by the fetal liver and yolk sac. In NTDs, the incomplete closure of the neural tube allows for leakage of AFP into the amniotic fluid and subsequently into the maternal bloodstream, leading to elevated serum levels.
Choice B rationale
Phenylketonuria (PKU) is an autosomal recessive metabolic disorder characterized by a deficiency in the enzyme phenylalanine hydroxylase, leading to an accumulation of phenylalanine. It is typically identified through newborn screening, not through elevated maternal serum alpha-fetoprotein levels. MSAFP screening is not used for the diagnosis or suspicion of PKU.
Choice C rationale
Trisomy 21, also known as Down syndrome, is a chromosomal disorder caused by the presence of an extra copy of chromosome 21. While maternal serum screening for Trisomy 21 typically involves assessing multiple markers, including alpha-fetoprotein, low levels of MSAFP, in conjunction with abnormal levels of other markers like human chorionic gonadotropin (hCG) and unconjugated estriol, are generally indicative of Trisomy 21. Elevated AFP is not characteristic.
Choice D rationale
Hemophilia is a group of hereditary bleeding disorders caused by deficiencies in specific blood clotting factors, most commonly factor VIII (hemophilia A) or factor IX (hemophilia B). These disorders are genetically inherited and are not associated with or detected by elevated maternal serum alpha-fetoprotein levels. MSAFP is a screening tool for fetal structural anomalies, not coagulation disorders.
Correct Answer is D
Explanation
Choice A rationale
A nonstress test (NST) typically takes 20 to 40 minutes to complete, not 2 to 4 hours. The duration is usually sufficient to observe fetal heart rate accelerations in response to fetal movement, which is the primary indicator of fetal well-being during the test.
Choice B rationale
A nonstress test is performed to assess fetal well-being, especially in pregnancies at risk for uteroplacental insufficiency, such as those with post-term gestation, pre-eclampsia, or diabetes, not specifically because it is a first pregnancy.
Choice C rationale
The nonstress test primarily measures the fetal heart rate patterns in response to fetal movement. Contraction strength is measured during a contraction stress test or by internal uterine pressure catheter, which is a different diagnostic procedure.
Choice D rationale
The nonstress test evaluates the fetal heart rate accelerations in response to spontaneous fetal movement. This indicates a healthy central nervous system and adequate oxygenation of the fetus. A reactive NST shows at least two accelerations of 15 bpm above baseline, lasting at least 15 seconds, within a 20-minute period.
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