The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?

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The nurse should use a sterile glove during vaginal examination in the presence of ruptured membranes to prevent infection. Use of nonsterile gloves and instruments during vaginal examinations increases the risk of infection in the laboring client or fetus (eg, chorioamnionitis). (Option A) A nitrazine pH test strip inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal fluid, which is acidic. A blue-green, blue-gray, or deep blue color indicates a positive result and probable rupture of membranes. A yellow, olive-yellow, or olive green color indicates a negative result and suggests that membranes are intact. (Option C) Leopold maneuvers help determine fetal presentation and involve systematic palpation of the client's abdomen. These maneuvers assist the nurse in locating the fetal back for optimal placement of the ultrasound transducer for external fetal heart monitoring. (Option D) Hospital policy, provider preference, and the client risk profile will dictate appropriate oral intake during labor. However, there is no evidence to support NPO status of low-risk laboring clients, and most clients benefit from hydration provided by oral clear liquids during labor. Educational objective: Vaginal examinations of the laboring client with ruptured membranes should be performed using a sterile glove to decrease the risk of infection (eg, chorioamnionitis) to the client and fetus. Other labor admission interventions include application of external fetal monitoring and performance of a nitrazine pH test to determine if membranes have ruptured.

The Precepting Nurse Is Supervising a New Obstetric Nurse Performing