A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notes pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement?

• A. Escort the client to the bathroom
• B. Offer the client a bed pan
• C. Perform a nitrazine test
• D. Clean the perineal area

Answer: (C)

The situation hinges on confirming whether the membranes have actually ruptured. In labor, a sudden wet sensation with clear to pale straw-colored fluid and small particles can be amniotic fluid, but urine can look similar. The quickest way to tell is to use a nitrazine test. This pH-based test swabbed on the fluid will turn blue if the fluid is amniotic (alkaline, indicating rupture of membranes) and stay yellow if the fluid is acidic vaginal secretions or urine (membranes likely intact). Interpreting this helps guide infection risk management and subsequent care during labor. If the test result is blue, you’d continue appropriate monitoring and management for rupture of membranes; if not, you’d reassess the source of the fluid. The other actions don’t address the need to distinguish rupture versus urine, which is why the nitrazine test is the best immediate step.