NCLEX RN Exam Questions Practice Question
A female client admitted to the labor and delivery unit thinks her bag of water 'broke' approximately 2 hours ago. She is having mild contractions 5 minutes apart. The most immediate nursing intervention would be to:
Correct Answer: B
Rationale: Amniotic fluid is generally pale and straw colored. Meconium-stained amniotic fluid would indicate a previous hypoxic episode. This intervention, though appropriate, is not the immediate priority. With rupture of the membranes, the umbilical cord may prolapse if the presenting part does not fill the pelvis. Assessing FHR ascertains fetal well-being. More information regarding fetal status and assessing for membrane rupture is needed prior to contacting the physician. Nitrazine test paper differentiates amniotic fluid from urine. Amniotic fluid is normally alkaline in contrast to urine, which is acidic. This intervention, though appropriate, is not the immediate priority.
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