问题
单项选择题
Which assessment would the nurse perform to validate that the membranes are ruptured
A. Observe for a pink, mucus vaginal discharge.
B. Test the leaking fluid with nitrazine paper.
C. Assess the client’s temperature, pulse, and blood pressure.
D. Send a urine specimen from the client to be culture
答案
参考答案：B
解析：The nitrazine test determines whether the client’s membranes have ruptured. The nurse performs a sterile vaginal examination, inserts the nitrazine test tape, then assesses the tape for a color change. If the membranes are ruptured, the tape becomes bluish, which indicates that the vaginal environment is alkaline. If the test tape remains yellow or green, the vaginal environment is acidic, indicating that the membranes aren’t ruptured.