The nurse is assessing a patient who is 36 hours postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply.

Correct Answer: C

Rationale: The correct answer is C because increased margins of incisional redness are indicative of a wound infection, showing an inflammatory response. This can be a sign of localized infection spreading. The other choices are incorrect as follows: A: A slight temperature increase alone is not specific to wound infection and can be attributed to other factors. B: Incisional tenderness can be expected post-surgery and does not necessarily indicate infection. D: Notably warm skin around the incision can also occur due to normal healing processes and inflammation. Therefore, only choice C directly indicates a developing wound infection.

Correct Answer: C

Rationale: The correct answer is C: thrush. Thrush is a fungal infection caused by Candida that can be transmitted between the breast-feeding person and the newborn if not treated appropriately. The infection can pass back and forth during breastfeeding. Thrush manifests as white patches on the tongue and inside the mouth of the newborn and as nipple pain and redness in the breast-feeding person. Wound infection (A) typically refers to an infection at the site of a surgical incision and is not transmitted between the breast-feeding person and newborn. Urinary tract infection (B) is a bacterial infection of the urinary tract and is not typically transmitted through breastfeeding. Mastitis (D) is a bacterial infection of the breast tissue and is not directly transferred between the breast-feeding person and the newborn.

Correct Answer: A

Rationale: The correct answer is A: precipitous labor. Precipitous labor can cause trauma to the birth canal, leading to increased risk of infection. Urinary retention (B) may lead to urinary tract infections but not necessarily postpartum infections. Breastfeeding (C) and intact perineum (D) are not direct risk factors for postpartum infections.

Correct Answer: B

Rationale: The correct answer is B: Assess for REEDA. REEDA stands for Redness, Edema, Ecchymosis, Drainage, and Approximation, which are key indicators of wound infection. By assessing for REEDA, the nurse can monitor and evaluate the progress of the infection. This intervention allows for early detection and prompt treatment of wound infections. Choice A is incorrect because reassuring the postpartum person without antibiotics may lead to worsening infection. Choice C is incorrect as a temperature of 99.0° F is not necessarily indicative of a wound infection. Choice D is incorrect as scrubbing the incision vigorously with soap and water can introduce more bacteria and worsen the infection.

Correct Answer: A

Rationale: The correct answer is A: Monitor for signs of sepsis. Postpartum endometritis is a bacterial infection of the uterine lining that can lead to sepsis if not treated promptly. Monitoring for signs of sepsis is crucial for early detection and intervention to prevent serious complications. Option B is incorrect because breastfeeding is encouraged to promote bonding and provide nutrition. Option C is incorrect as fundal assessment is necessary to monitor uterine involution. Option D is incorrect as increasing family visiting hours is not directly related to managing postpartum endometritis.