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

Correct Answer: C

Rationale: The correct answer is C because using a peri-bottle for cleaning front to back helps prevent introducing more bacteria into the infected perineal laceration. This method maintains proper hygiene, reduces the risk of further infection, and promotes healing. A urinary catheter (A) is not typically indicated for a perineal laceration infection. An abdominal binder (B) may provide support but does not directly address the infection. Discouraging pain medications (D) is not appropriate as pain management is important for patient comfort and healing.

Correct Answer: A

Rationale: The correct answer is A because in the context of Postpartum Hemorrhage (PPH), the 4 T’s stand for Tone, Trauma, Tissue, and Thrombin. Tissue refers to placental tissue or membranes being retained, leading to excessive bleeding. This can be a common cause of PPH. Option B is incorrect because it refers to perineal tears, which are related to trauma and not specifically related to tissue retention causing PPH. Option C is incorrect as it refers to uterine tissue tears, which is more related to trauma rather than retained tissue. Option D is incorrect because it refers to tissue not being perfused, which is not directly related to the concept of tissue retention causing PPH.

Correct Answer: C

Rationale: The correct answer is C: von Willebrand disorder. This is a risk factor for postpartum hemorrhage (PPH) as it can lead to abnormal bleeding during and after childbirth. von Willebrand disorder is a hereditary bleeding disorder that affects the blood's ability to clot properly. This can increase the likelihood of excessive bleeding during delivery, putting the mother at risk for PPH. Choice A: primipara is incorrect, as being a first-time mother (primipara) is not a direct risk factor for PPH. Choice B: rubella nonimmune is incorrect, as rubella immunity status is not directly related to the risk of PPH. Choice D: history of appendectomy is incorrect, as a previous appendectomy is not a known risk factor for PPH. In summary, the presence of von Willebrand disorder in the prenatal record is a significant risk factor for PPH due to its impact on blood clotting ability during childbirth.

Correct Answer: D

Rationale: The correct answer is D: Start an IV bolus. In postpartum hemorrhage (PPH), the priority is to restore circulating volume quickly to prevent shock. Starting an IV bolus with fluids or blood products helps improve perfusion and oxygenation. Choice A is incorrect as warming the person does not address the underlying issue of hypovolemia. Choice B is incorrect as monitoring oxygen saturation is not the immediate priority. Choice C is incorrect as sitting the person up could potentially worsen their condition by reducing venous return.

Correct Answer: B

Rationale: The correct answer is B: risk for fluid overload. A person with a coagulation disorder is at risk for excessive bleeding, which may lead to fluid overload due to blood loss and subsequent fluid replacement. This nursing diagnosis addresses the potential complications related to fluid imbalance in this population. Incorrect choices: A: risk for bleeding - While bleeding is a concern for someone with a coagulation disorder, this choice does not address the potential fluid overload that may result from excessive bleeding. C: risk for breast-feeding failure - This choice is not relevant to the immediate health concerns of a person with a coagulation disorder. D: risk for hypertension - Hypertension is not directly related to a coagulation disorder, therefore this choice is not appropriate as a nursing diagnosis in this context.