What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?

Correct Answer: A

Rationale: In the context of postpartum endometritis, which is an infection of the uterine lining following childbirth, the correct nursing intervention of monitoring for signs of sepsis (Option A) is crucial. Endometritis can lead to systemic infection, including sepsis, which is a life-threatening condition. By monitoring for signs of sepsis such as fever, rapid heart rate, low blood pressure, and altered mental status, the nurse can promptly identify and initiate appropriate treatment to prevent further complications. Option B, discouraging breastfeeding, is incorrect. Breastfeeding is not contraindicated in cases of endometritis unless there are specific reasons such as the mother being on medications that are unsafe for the baby. Option C, avoiding fundal assessment, is also incorrect. Fundal assessment is important postpartum to monitor uterine involution and to detect any abnormalities such as excessive bleeding that may indicate complications like hemorrhage, not specifically related to endometritis. Option D, increasing family visiting hours, is not a priority intervention for a person with postpartum endometritis. While family support is important, the immediate focus should be on monitoring for and managing the infection to prevent further complications. In an educational context, understanding the rationale behind each nursing intervention is crucial for providing safe and effective care to patients. Nurses need to prioritize interventions based on the patient's condition and the potential risks involved to ensure optimal outcomes. Monitoring for signs of sepsis in a person with postpartum endometritis is a critical nursing intervention that can ultimately save lives by enabling early detection and treatment of a potentially life-threatening complication.

Correct Answer: C

Rationale: In the context of postpartum complications, uterine atony is a significant concern due to its association with postpartum hemorrhage. Uterine atony occurs when the uterus fails to contract effectively after childbirth, leading to excessive bleeding. Multiple gestation (Option C) is a risk factor for uterine atony because the uterus is often distended and larger in multiple gestations, making it more difficult for the uterus to contract effectively and leading to an increased risk of atony. Options A, B, and D are not directly related to uterine atony. Being small for gestational age (Option A) does not inherently increase the risk of uterine atony. Primiparity (Option B), or being a first-time mother, is not a direct risk factor for uterine atony, although primiparas may have a slightly higher risk of postpartum hemorrhage in general. Intrauterine growth restriction (Option D) is a condition where a fetus does not reach its growth potential in the uterus, but it is not a direct risk factor for uterine atony. Understanding risk factors for postpartum complications like uterine atony is crucial for healthcare providers involved in maternal care. By recognizing these risk factors, healthcare professionals can implement preventive measures and interventions to manage and reduce the incidence of complications, ensuring better outcomes for both mother and baby.

Correct Answer: D

Rationale: In this scenario, the correct intervention is option D: Massage the fundus and assess the lochia. This is the appropriate action because a boggy uterus combined with a full bladder can indicate uterine atony, which is a common postpartum complication leading to excessive bleeding. Massaging the fundus helps the uterus contract, controlling bleeding, while assessing the lochia provides information about the amount and character of postpartum bleeding, aiding in the evaluation of the patient's condition. Option A (Call for help) is not the immediate action needed in this situation. While help may eventually be required, addressing the physiological issue should be the priority. Option B (Start IV bolus) is also not the first step because the primary concern is managing the uterine atony and potential hemorrhage. Fluid resuscitation may be necessary later, but it is not the initial intervention. Option C (Get the person out of bed to walk to restroom) is incorrect as it does not address the urgent need to manage the uterine atony and assess for postpartum hemorrhage. Moving the patient could potentially worsen the bleeding if the uterine atony is not addressed first. This scenario highlights the critical importance of prompt assessment and intervention in the postpartum period to prevent and manage complications effectively. Nurses need to be knowledgeable about postpartum complications and skilled in recognizing and addressing them promptly to ensure positive outcomes for both the mother and the newborn.

Correct Answer: A

Rationale: In postpartum care, assessing fluid volume status is crucial to prevent complications. The correct answer is A) skin tenting with testing of skin turgor. Skin tenting occurs when the skin does not return to its normal position immediately after being pinched, indicating dehydration and a fluid volume deficit. Testing skin turgor helps evaluate the skin's elasticity, which decreases with dehydration. Option B) hypertension is not indicative of a fluid volume deficit but could suggest other conditions like preeclampsia. Option C) bradycardia is also not a typical finding in fluid volume deficit but could be seen in severe cases of dehydration or shock. Option D) bounding pulse is associated with fluid volume excess, not deficit. Educationally, understanding these assessment findings in the context of postpartum care is essential for nurses and healthcare providers to provide appropriate interventions promptly and prevent complications like hypovolemic shock. Regular assessment and early recognition of signs of fluid volume imbalance are vital in ensuring maternal well-being postpartum.

Correct Answer: C

Rationale: In the context of postpartum complications, the most common reason for cracked, sore nipples is an ineffective latch (option C). This is because a poor latch can lead to improper positioning of the infant's mouth on the breast, causing friction and trauma to the nipple tissue. Option A, a hungry infant, is incorrect because even a well-fed baby can cause nipple soreness if the latch is ineffective. Option B, pumping, is also incorrect as pumping, when done correctly, should not cause cracked, sore nipples. Option D, lack of supportive bra, is not directly related to the issue of cracked, sore nipples resulting from breastfeeding. Educationally, it is crucial for healthcare providers and new mothers to understand the importance of a proper latch to prevent nipple complications. Teaching proper breastfeeding techniques, including correct positioning and latch, can help alleviate nipple pain and encourage successful breastfeeding. Providing support and guidance to mothers can improve their breastfeeding experience and overall postpartum health.