“A nurse is caring for a patient who reports spontaneous rupture of membranes.

The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding.

After calling for assistance and notifying the provider, which of the following actions should the nurse take next?”

Choice A rationale
Administering an IV bolus of lactated Ringer’s is not the best action for a client with peripartum cardiomyopathy. This condition is a form of heart failure that occurs during the last month of pregnancy or up to five months postpartum. It can lead to fluid overload, so giving an IV bolus of lactated Ringer’s could exacerbate the client’s condition.
Choice B rationale
Assessing blood pressure twice daily is important for any postpartum client, but it is not the most critical action for a client with peripartum cardiomyopathy. This condition can lead to fluid overload and heart failure, so while monitoring blood pressure is important, it is not the primary intervention.
Choice C rationale
Restricting daily oral fluid intake is the correct action. Peripartum cardiomyopathy can lead to fluid overload and heart failure. Restricting fluid intake can help manage the client’s fluid status and prevent exacerbation of heart failure.
Choice D rationale
Obtaining a prescription for misoprostol is not relevant in this context. Misoprostol is a medication used to prevent stomach ulcers in patients taking NSAIDs and to induce labor or cause an abortion. It has no role in the management of peripartum cardiomyopathy.

Choice A rationale
A score of 9 on the Edinburgh Postnatal Depression Screen (EPDS) on postpartum day 2 is below the clinical cutoff score of 10, which is used to distinguish health controls versus possible depression. Therefore, this score would not indicate a high risk of developing a depressive disorder.
Choice B rationale
A score of 11 on the EPDS on postpartum day 30 is above the clinical cutoff score of 1034. This score indicates a high risk of developing a depressive disorder. Therefore, further assessment and possible intervention would be necessary.
Choice C rationale
While discharge teaching is an important aspect of postpartum care, it does not provide information about the client’s risk of developing postpartum depression. Therefore, this choice does not answer the question.
Choice D rationale
A follow-up appointment with a provider in 4 weeks is a standard part of postpartum care, but it does not provide information about the client’s risk of developing postpartum depression.
Therefore, this choice does not answer the question.