# Situation: A 27-year-old woman, gravida 2 para 1, is at 30 weeks' gestation and attends a prenatal visit at a hospital outpatient department. Her pregnancy has been uncomplicated, and her 4-year-old son comes with her. Four days after this visit, she calls the clinic. Since early morning she has had a thin, watery vaginal discharge that has dampened her underwear several times. It has no odor, and she has no itching, pain, or contractions. The baby is moving as usual. Which response by the nurse is BEST?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A 27-year-old woman, gravida 2 para 1, is at 30 weeks' gestation and attends a prenatal visit at a hospital outpatient department. Her pregnancy has been uncomplicated, and her 4-year-old son comes with her.

Four days after this visit, she calls the clinic. Since early morning she has had a thin, watery vaginal discharge that has dampened her underwear several times. It has no odor, and she has no itching, pain, or contractions. The baby is moving as usual. Which response by the nurse is BEST?

## 보기

1. "Wear a pad, rest, and come in if contractions start."
2. "Come to the hospital now so the fluid can be examined." **✔ 정답**
3. "Lie on your left side and count the baby's kicks for 2 hours."
4. "More discharge is normal now; keep the area clean and dry."

**정답: 2**

## 해설

Repeated wetting with thin, watery fluid may be leaking amniotic fluid, a danger sign that needs evaluation at once even without pain or contractions. Leukorrhea, the normal increased discharge of pregnancy, is thicker and whitish and does not repeatedly soak the underwear. Waiting for contractions or counting movements delays assessment for ruptured membranes and infection.

## 심화 해설

Clinical situation

A 27-year-old woman at 30 weeks gestation reports a thin, watery vaginal discharge that has repeatedly dampened her underwear since early morning. The fluid is odorless, and she denies itching, pain, or contractions. Fetal movement is unchanged. These features are highly suggestive of leaking amniotic fluid, which requires immediate evaluation.

Why the correct answer is “Come to the hospital now so the fluid can be examined”

The priority concern is preterm prelabor rupture of membranes (preterm PROM), defined as rupture of the fetal membranes before the onset of labor at less than 37 weeks gestation. The woman’s description of thin, watery fluid that soaks her underwear repeatedly is the classic presentation of amniotic fluid leakage. Even in the absence of pain, contractions, or fever, membrane rupture must be confirmed or excluded promptly because it exposes the pregnancy to serious risks.

A history of repeated wetting with thin, watery fluid is a danger sign that requires same-day clinical assessment, not watchful waiting at home. The correct nursing action is to bring the patient in for sterile speculum examination, nitrazine pH testing, ferning, and ultrasound assessment of amniotic fluid volume. Delaying this evaluation increases the window for ascending infection and umbilical cord complications.

Watch out! Normal pregnancy discharge, or leukorrhea, is thicker, whitish or milky, and does not repeatedly soak undergarments. The key discriminator in this scenario is the thin, watery consistency and the repeated soaking pattern.

Why the other options are unsafe or incomplete

| Option | Problem |
| --- | --- |
| 1. “Wear a pad, rest, and come in if contractions start.” | This delays diagnosis. Preterm PROM can occur without contractions, and infection risk increases with time. Waiting for contractions misses the window for timely evaluation and possible intervention. |
| 3. “Lie on your left side and count the baby’s kicks for 2 hours.” | Kick counting assesses fetal well-being but does not diagnose membrane rupture. Fetal movement is reported as normal, so this does not address the primary concern of possible amniotic fluid leakage. |
| 4. “More discharge is normal now; keep the area clean and dry.” | This incorrectly attributes a potentially serious sign to normal physiologic leukorrhea. While increased discharge is common in pregnancy, thin watery fluid that repeatedly soaks underwear is not typical and must be evaluated. |

Pathophysiology and clinical risk of preterm PROM

The fetal membranes form a protective barrier between the sterile intra-amniotic environment and the vaginal flora. When the membranes rupture before labor, this barrier is compromised. Loss of membrane integrity facilitates ascending microbial invasion from the lower genital tract into the amniotic cavity, increasing the risk of chorioamnionitis and neonatal sepsis. The longer the interval between rupture and delivery, the greater the infectious risk.

At 30 weeks gestation, the fetus is still preterm. Preterm PROM complicates approximately 3% of pregnancies in the United States and is a major contributor to perinatal morbidity and mortality. Management decisions depend heavily on accurate confirmation of membrane status and gestational age. Conservative management may be considered at this gestation, but only after the diagnosis is established in a clinical setting.

Nursing priorities in suspected preterm PROM

The immediate nursing responsibility is to facilitate prompt medical evaluation. Key steps include:

| Priority action | Rationale |
| --- | --- |
| Instruct the patient to come to the hospital now | Confirmation of membrane rupture requires sterile speculum examination and laboratory testing that cannot be done by telephone. |
| Advise against vaginal exams or intercourse before evaluation | Digital cervical examination can introduce bacteria into the amniotic cavity and increase infection risk when membranes are ruptured. |
| Assess for signs of infection, cord prolapse, and labor | Fever, maternal or fetal tachycardia, uterine tenderness, purulent discharge, or a palpable cord are emergencies requiring immediate intervention. |
| Monitor fetal well-being | Oligohydramnios from fluid loss can lead to cord compression and non-reassuring fetal heart patterns. |

Key point! The absence of contractions, pain, or fever does not rule out ruptured membranes. A patient who reports thin, watery fluid that repeatedly soaks her underwear at 30 weeks gestation must be evaluated in person the same day. Telephone reassurance or home monitoring instructions are inappropriate until membrane rupture has been excluded.

## 임상 시나리오

Preterm PROM TriageThin watery leakage at 30 weeks needs same-day evaluation
Repeated wetting with thin, watery fluid that soaks underwear is a classic sign of amniotic fluid leakage, not normal discharge. Bring the patient in for sterile speculum examination, nitrazine pH testing, ferning, and ultrasound assessment of amniotic fluid volume.

Leukorrhea, the normal increased discharge of pregnancy, is thicker and whitish and does not repeatedly soak undergarments. Thin, odorless, watery leakage without itching or pain should be treated as ruptured membranes until proven otherwise.

CautionDo not wait for contractions or rely on kick counts. Delaying assessment increases the risk of ascending infection and umbilical cord complications.

## 핵심 개념

- **preterm PROM** — Rupture of fetal membranes before onset of labor at less than 37 weeks gestation, requiring immediate evaluation for infection and cord complications.
- **leukorrhea** — Normal increased vaginal discharge of pregnancy that is thicker, whitish or milky, and does not repeatedly soak undergarments.
- **nitrazine pH testing** — A test used to help identify amniotic fluid; amniotic fluid is alkaline and turns nitrazine paper blue.
- **ferning** — Microscopic arborization pattern seen when amniotic fluid dries on a slide, used to confirm membrane rupture.
- **sterile speculum examination** — Aseptic visual inspection of the cervix and vaginal vault to assess for pooling of amniotic fluid and to collect samples.

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