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

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: B

Rationale: The correct answer is B because late (secondary) postpartum hemorrhage (PPH) is typically caused by subinvolution of the uterus, leading to persistent bleeding after the first 24 hours postpartum. This is due to inadequate contraction of the uterus to stop bleeding from the placental site. Choice A is incorrect because a late PPH occurs after the first 24 hours, not within it. Choice C is incorrect because late PPH can occur after cesarean births as well. Choice D is incorrect because Methergine is commonly used to treat late PPH by promoting uterine contractions and controlling bleeding.

Correct Answer: C

Rationale: The correct answer is C: multiple gestation. Multiple gestation is a risk factor for uterine atony due to the increased uterine size and stretched muscle fibers, which can lead to decreased uterine tone postpartum. This can result in excessive bleeding. A: Small for gestational age is not typically a risk factor for uterine atony as it refers to the size of the baby, not the uterus. B: Primipara (first-time mother) may have a higher risk of uterine atony due to less uterine tone from lack of previous pregnancies, but it is not as significant as multiple gestation. D: Intrauterine growth restriction refers to the baby's growth, not the mother's risk of uterine atony.

Correct Answer: D

Rationale: Step-by-step rationale: 1. A boggy uterus indicates uterine atony, a common cause of postpartum hemorrhage. 2. A full bladder can prevent the uterus from contracting effectively. 3. Massaging the fundus helps stimulate contractions to prevent further bleeding. 4. Assessing lochia provides information on the amount and type of bleeding. 5. This intervention addresses the underlying issue and promotes uterine contraction, reducing the risk of hemorrhage. Other choices are incorrect: A: Calling for help is not the immediate intervention needed to address the uterine atony and full bladder. B: Starting an IV bolus may be necessary later but is not the priority in this situation. C: Getting the person out of bed is not appropriate when managing postpartum hemorrhage; addressing uterine atony is crucial.

Correct Answer: A

Rationale: The correct answer is A because skin tenting with testing of skin turgor is a classic sign of fluid volume deficit. When there is a lack of fluid in the body, the skin loses its elasticity, causing it to tent or stay elevated when pinched. This indicates dehydration. Choice B, hypertension, is incorrect because fluid volume deficit typically leads to hypotension, not hypertension. Choice C, bradycardia, is also incorrect as fluid volume deficit usually causes tachycardia to compensate for decreased blood volume. Choice D, bounding pulse, is incorrect as it is associated with fluid overload, not deficit.