The nurse assesses a client at term gestation who reports having contractions for the last 2 hours. The client states, "I'm not sure, but I think my water broke." The nurse performs a nitrazine pH test, which turns blue. When documenting the results of the test, which client statement is most concerning to the nurse?

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11ecbb05_cbf6_007c_b433_915934709816_MD0009_00 Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. A yellow, olive, or green color suggests that amniotic membranes are intact. A bluish color suggests probable rupture of membranes (ROM). However, the presence of blood or semen may result in a false positive, as serum and prostatic fluid are alkaline. A client history of recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen in the vagina (Option A). (Option B) Constant wetness of undergarments may indicate leaking amniotic fluid. This statement is not concerning and substantiates the positive nitrazine results and the client's history. (Option C) Occasional involuntary urine leakage is common late in the third trimester as the gravid uterus presses on the bladder. Urine is generally acidic and should not inhibit nitrazine testing or cause a false positive. (Option D) Many clients have never experienced spontaneous ROM, especially if previous labors were induced. This statement does not inhibit the nurse's ability to judge the accuracy of nitrazine results. Educational objective: A nitrazine pH test strip can differentiate between alkaline amniotic fluid and vaginal secretions or urine, which are acidic. Recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen (ie, an alkaline fluid) in the vagina.

The Nurse Assesses a Client at Term Gestation Who Reports