After ambulating in the hall and returning to bed, the client states that her water broke.
The fetal heart rate is 85 beats per minute, and the vaginal exam reveals the cervix is 90% effaced, 2 cm dilated, vertex presentation, and fetal station -2. There is a pulsating cord felt in the anterior portion of the vagina.
Which intervention would the nurse perform immediately?

The correct answer is Choice A, Choice D, Choice E.

Choice A rationale

Pain during intercourse, also known as dyspareunia, is a common symptom of endometriosis. Endometrial tissue growing outside the uterus can infiltrate the pelvic organs and ligaments, causing pain and discomfort during sexual activity due to pressure and inflammation in these areas.

Choice B rationale

Painless heavy menstrual bleeding is not typically associated with endometriosis. Endometriosis is characterized by the presence of endometrial-like tissue outside the uterus, which responds to hormonal fluctuations of the menstrual cycle, often leading to painful periods (dysmenorrhea) and potentially heavy bleeding accompanied by pain.

Choice C rationale

Unexplained weight gain is not a typical symptom directly linked to endometriosis. While hormonal imbalances can occur with endometriosis, they do not usually manifest as unexplained weight gain. Other factors are more likely to contribute to weight changes.

Choice D rationale

Infertility is a significant concern for many individuals with endometriosis. The presence of endometrial implants, adhesions, and scarring in the pelvic cavity can distort the anatomy of the reproductive organs, interfering with ovulation, fertilization, and implantation of a fertilized egg.

Choice E rationale

Pain during the menstrual period, known as dysmenorrhea, is a hallmark symptom of endometriosis. The ectopic endometrial tissue undergoes cyclical bleeding and shedding, similar to the uterine lining, but this occurs outside the uterus, causing inflammation, pain, and potentially the formation of scar tissue and adhesions.

Choice A rationale

Placenta previa is a condition where the placenta implants in the lower part of the uterus, potentially covering the cervix. This typically presents with painless vaginal bleeding, not the elevated blood pressure seen in this client.

Choice B rationale

Placental abruption involves the premature separation of the placenta from the uterine wall. This often manifests with sudden abdominal pain, vaginal bleeding, and uterine tenderness, which are not the primary findings in this postpartum client.

Choice C rationale

Postpartum hemorrhage is excessive bleeding after childbirth, typically defined as more than 500 mL after vaginal delivery or 1000 mL after cesarean birth. While prolonged labor can increase the risk, the client's current vital signs do not indicate active hemorrhage.

Choice D rationale

Preeclampsia can occur postpartum, characterized by new-onset hypertension (blood pressure ≥ 140/90 mmHg) and proteinuria or other signs of end-organ damage within 4 weeks after delivery. This client's blood pressure of 150/86 mmHg, coupled with a history of prolonged labor and being a primipara (both risk factors for preeclampsia), makes this the most likely condition. Normal postpartum blood pressure typically returns to the client's baseline pre-pregnancy levels.