The nurse reviews the assessment findings along with the healthcare provider's prescriptions.
Which immediate intervention(s) would the nurse initiate? Select all that apply.

Choice A rationale

Palpating the suprapubic area to assess fetal head position is not relevant to identifying the source of fluid leakage. This technique is used to evaluate fetal engagement in the pelvis, particularly near term, but it does not help in determining whether the fluid leakage is amniotic fluid or urine.

Choice B rationale

Scanning the bladder for urinary retention is unrelated to identifying the nature of fluid leakage. A bladder scan is useful for detecting residual urine volume in the bladder, often post-voiding, and is typically used in cases of urinary retention or post-operative care.

Choice C rationale

Testing the fluid with a nitrazine strip is a standard method to distinguish amniotic fluid from urine or vaginal secretions. Amniotic fluid has a higher pH (usually between 7.0 and 7.5), causing the nitrazine strip to turn blue, whereas urine and vaginal secretions usually have a lower pH, resulting in a yellow or green color on the strip.

Choice D rationale

Inserting a straight urinary catheter to drain the bladder is an invasive procedure that does not directly identify the source of fluid leakage. This technique is typically used to relieve urinary retention or to collect a sterile urine specimen, not for diagnosing amniotic fluid leakage.

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.