2024 PN NCLEX Questions Nursing Practice Question
A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?
Correct Answer: D
Rationale: Documenting the findings is essential for maintaining accurate medical records and ensuring continuity of care. Clear amniotic fluid with creamy white flecks typically indicates normal conditions, thus immediate intervention is not necessary.
Checking the client’s temperature (A) is important in cases of suspected infection but is not the priority here, as the fluid appears normal. Reporting to the nurse-midwife (B) is unnecessary unless there are concerning signs, which are absent in this scenario. Obtaining a sample for laboratory analysis (C) is not warranted given the normal appearance of the fluid, which does not indicate the need for further testing.