Health Promotion and Maintenance
30. A client who is at 38 weeks' gestation presents to labor and delivery and states, "I have water leaking down my legs." Which assessment by a nurse is most appropriate in this situation?
Health Promotion and Maintenance
30. A client who is at 38 weeks' gestation presents to labor and delivery and states, "I have water leaking down my legs." Which assessment by a nurse is most appropriate in this situation?
Test-Taking Tip
When you see "assessment" or "evaluation" in the stem of the question, think about an assessment specific to this case and not applicable in general.
Content Area: Maternity, Intrapartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Health Promotion and Maintenance
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Answer 1 is incorrect because deep tendon reflexes are a part of every labor assessment and are not specific to rupture of membranes. Answer 2 is correct because the fern test is done to check for ruptured membranes. It is positive if the amniotic sac has broken. Answer 3 is incorrect because a blood pressure check is a part of every labor assessment and is not specific to rupture of membranes. Answer 4 is incorrect because a urine test for protein is a part of every labor assessment and is not specific to rupture of membranes.
