A nurse is caring for a client who is receiving a continuous intravenous infusion containing a vesicant that has become infiltrated. Which of the following actions should the nurse take first in treating this condition?

A. "The test will determine if there is leaking amniotic fluid.": The nitrazine test is used to detect the presence of amniotic fluid in the vagina by measuring pH. A positive result indicates a more alkaline pH, suggesting rupture of membranes. This explanation accurately describes the purpose of the test to the client.

B. "Your bladder should be full prior to me performing this test.": A full bladder is not required for a nitrazine test. In fact, urine can interfere with results because it is acidic and may cause a false-negative reading, so the bladder should not influence the test outcome.

C. "I will be taking a blood sample to test for changes in your hormone levels.": The nitrazine test does not involve blood samples and is unrelated to hormone levels. It is performed using vaginal fluid to detect amniotic fluid, so this statement is inaccurate.

D. "If this test is positive you will be required to have a non-stress test.": A positive nitrazine test indicates ruptured membranes, which may require further assessment, but it does not automatically mandate a non-stress test. Additional evaluation and clinical judgment guide next steps rather than an automatic NST.

Rationale

• Irrigate indwelling urinary catheter with 50 mL normal saline: Following perineal prostatectomy, bladder spasms, pink urine, and a sensation of fullness can indicate catheter blockage from clots. Gentle irrigation with a small volume ensures catheter patency and relieves obstruction. The client’s decreasing urine output despite increased intake further supports the need for irrigation. Restoring flow prevents retention and reduces discomfort from bladder spasms.

• Apply warm compresses to the incision site: Heat increases vasodilation and can worsen postoperative bleeding in a highly vascular perineal area. A prostatectomy incision requires protection from excessive warmth to reduce hemorrhage risk. Additionally, warm compresses could increase swelling and discomfort.

• Maintain bed rest for 2 days postoperatively: Early ambulation is essential to prevent postoperative complications such as DVT, which is especially important given the client’s history of thrombosis. This client is already independently ambulating, which should be encouraged. Bed rest would increase clot formation risk and impair bowel function, worsening constipation and pain.

• Place a blanket roll under the client’s knees while in bed: Placing pillows or rolls under the knees promotes venous stasis and increases DVT risk, which is dangerous for this client with a past history of thrombosis. Knee flexion also strains the perineal surgical area and may increase pain. Maintaining legs flat encourages optimal circulation and reduces risk of clot formation.