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: In the context of postpartum care after a cesarean delivery, it is crucial for nurses to be able to recognize signs of wound infection promptly. Option C, increased margins of incisional redness, is the correct answer in this scenario. This finding indicates a spreading infection that needs immediate attention. Option A, a mild increase in temperature, could be a normal postpartum finding or result from other causes, so it is not a definitive sign of wound infection. Option B, incisional tenderness with palpation, can be expected as part of normal wound healing and may not necessarily indicate infection unless accompanied by other signs. Option D, notably warm skin around the incision, could be attributed to localized inflammation or increased blood flow to the area as part of the healing process, rather than a clear indicator of infection. Educationally, understanding the subtle differences in postpartum assessments is essential for nurses to provide safe and effective care. Recognizing the specific signs of wound infection helps in timely intervention and prevention of complications for the mother. This case highlights the importance of thorough assessment and clinical judgment in postpartum care, ensuring optimal outcomes for both the mother and the newborn.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) thrush. Thrush is a fungal infection caused by Candida albicans that can be passed between the breast-feeding person and newborn if not treated appropriately. It commonly presents as white patches on the inside of the baby's mouth or on the mother's nipples. Option A) wound infection is less likely to be transferred between the breast-feeding person and newborn as it usually involves a localized wound site. Option B) urinary tract infection is typically not directly transmitted between the breast-feeding person and newborn. Option D) mastitis is a common postpartum complication in breast-feeding individuals, but it is not directly transmissible to the newborn unless there is a severe systemic infection. Educationally, understanding the risks of postpartum infections and their transmission is crucial for healthcare providers caring for postpartum individuals and newborns. Proper education on prevention, early recognition, and treatment of these infections can help prevent complications and promote the health of both the mother and the newborn.

Correct Answer: A

Rationale: In the context of postpartum complications, understanding the risk factors for postpartum infection is crucial for providing optimal care to postpartum women. Option A, precipitous labor, is the correct answer because it can lead to increased tissue trauma, which creates a favorable environment for bacterial growth and infection. In precipitous labor, the rapid delivery can cause lacerations or tears in the birth canal, increasing the risk of infection. Option B, urinary retention, does not directly increase the risk of postpartum infection. While urinary retention can lead to urinary tract infections if left untreated, it is not a direct risk factor for postpartum infections. Option C, breastfeeding, is not a primary risk factor for postpartum infection. Breastfeeding is beneficial for the mother and baby, providing numerous health benefits, and does not inherently increase the risk of postpartum infection. Option D, intact perineum, does not increase the risk of postpartum infection. An intact perineum means that there are no lacerations or tears, reducing the risk of infection compared to having perineal trauma. Educationally, understanding the risk factors for postpartum infections helps healthcare providers identify high-risk patients, implement preventive measures, and provide appropriate treatment promptly. By knowing which assessment data points increase the risk of postpartum infection, healthcare providers can offer individualized care and improve outcomes for postpartum women.

Correct Answer: B

Rationale: In the context of postpartum wound infection, the correct nursing intervention to include in the plan of care is to assess for REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation of wound edges). This is the correct answer because assessing for REEDA provides crucial information about the status of the wound infection, guiding appropriate treatment and interventions. Option A is incorrect because reassuring the postpartum person that the infection will resolve without antibiotics is not evidence-based practice and can lead to complications if the infection worsens. Option C is incorrect as waiting until the temperature is 99.0° F to call the healthcare provider may delay necessary treatment for the wound infection. Option D is incorrect as vigorous scrubbing of the incision with soap and water can further aggravate the wound and increase the risk of infection. In an educational context, it is important for nurses to understand the significance of proper wound assessment techniques like REEDA in identifying and managing postpartum wound infections promptly. Teaching nursing students to prioritize assessment skills and evidence-based interventions in the care of postpartum individuals can improve patient outcomes and prevent complications.

Correct Answer: A

Rationale: In the context of postpartum endometritis, which is an infection of the uterine lining following childbirth, the correct nursing intervention included in the plan of care is to monitor for signs of sepsis (Option A). This is crucial because endometritis can lead to sepsis, a life-threatening condition characterized by a systemic response to infection. By closely monitoring for signs of sepsis such as elevated heart rate, fever, hypotension, and altered mental status, the nurse can promptly intervene and prevent the progression to septic shock. Option B, discouraging breast-feeding, is incorrect as breast-feeding is encouraged in postpartum care due to its numerous benefits for both the mother and the newborn, unless contraindicated by specific medications used in the treatment of endometritis. Option C, avoiding fundal assessment, is also incorrect as routine fundal assessment is essential in monitoring postpartum uterine involution and detecting any abnormal findings that may indicate complications such as retained placental fragments or excessive bleeding. Option D, increasing family visiting hours, is not a priority intervention in the case of postpartum endometritis. While family support is important in the postpartum period, the immediate focus should be on the patient's clinical condition and preventing complications like sepsis. In an educational context, understanding the rationale behind the correct intervention of monitoring for signs of sepsis highlights the importance of early recognition and intervention in preventing life-threatening complications in postpartum patients. Nurses must be diligent in assessing and monitoring patients for signs of deterioration, especially in the context of postpartum infections, to provide safe and effective care.