Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Choice A rationale

A speculum exam to test for fetal fibronectin is primarily used to predict the risk of preterm labor in symptomatic women between 22 and 34 weeks of gestation. Since the client is at 37 weeks of gestation (term) and the concern is a slow trickle of fluid suggesting rupture of membranes (ROM), this test is not appropriate for the current clinical presentation or gestational age.

Choice B rationale

Nitrazine testing is a rapid, non-invasive method used to determine if the fluid leaking from the vagina is amniotic fluid. Amniotic fluid is alkaline (pH of 7.0 to 7.5) and will turn the yellow-to-orange nitrazine paper to a characteristic deep blue color, which helps confirm the diagnosis of premature rupture of membranes (PROM), a likely cause of the reported fluid trickle.

Choice C rationale

A urinalysis determines components like protein, glucose, and ketones, and is mainly used to screen for conditions such as preeclampsia (indicated by proteinuria) or urinary tract infection (UTI). While part of routine prenatal care, it is not the diagnostic test for confirming ruptured membranes, which is the primary concern given the client's report of a slow trickle of vaginal fluid.

Choice D rationale

Amniocentesis is an invasive procedure used to aspirate amniotic fluid, typically to assess fetal lung maturity (L/S ratio) or for genetic testing. Since the client is at 37 weeks and the suspicion is ruptured membranes, which warrants immediate action due to infection risk, the risks and benefits of an amniocentesis for lung maturity are not justified.

Choice A rationale

Limiting visitors solely to immediate family is a hospital policy matter and while it may reduce traffic, it does not directly address the active physical security measures necessary to prevent infant abduction, which relies on a multi-faceted approach including staff vigilance, electronic systems, and parent education.

Choice B rationale

Sending the newborn to the nursery is a practice that increases the distance between the parent and the infant, potentially decreasing immediate parental observation and vigilance. Current best practices emphasize "rooming-in" to keep the newborn at the bedside, promoting bonding and constant parental awareness of the infant's whereabouts.

Choice C rationale

Checking identification badges of staff is a critical, active security measure that empowers parents as the final checkpoint in infant protection, ensuring only authorized and verifiable personnel handle the newborn. This reduces the risk of abduction by individuals impersonating hospital staff.

Choice D rationale

The electronic monitoring band is a vital part of the hospital's security system, often triggering an alarm if the infant is moved near an exit or beyond a designated area. Removing this band at any time, even for bathing, compromises the continuous electronic surveillance and increases the risk of abduction.