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 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.

Correct Answer: C

Rationale: In the context of postpartum complications, uterine atony refers to the inability of the uterus to contract effectively after childbirth, leading to excessive postpartum bleeding. Multiple gestation (Option C) is a known risk factor for uterine atony because the uterus becomes overstretched due to the presence of more than one fetus, making it harder for the uterus to contract effectively post-delivery. Primipara (Option B), a woman giving birth for the first time, is not a direct risk factor for uterine atony. Small for gestational age (Option A) and intrauterine growth restriction (Option D) refer to fetal size and growth issues, which are not directly related to the uterine muscle's ability to contract effectively. Educationally, understanding risk factors for postpartum complications like uterine atony is crucial for healthcare providers involved in obstetric care. Recognizing these risk factors allows for timely interventions to prevent or manage complications, ultimately improving maternal outcomes and reducing morbidity and mortality rates associated with childbirth.

Correct Answer: D

Rationale: In this scenario, the correct intervention for the nurse to perform next is option D, which is to massage the fundus and assess the lochia. This intervention is crucial in managing a boggy uterus, as massage helps the uterus to contract, preventing excessive bleeding and promoting involution. Assessing the lochia provides information about the amount and character of postpartum bleeding, which is essential in monitoring the patient's condition. Option A, calling for help, is not the immediate priority in this situation. The nurse should first take action to address the issue at hand before seeking additional assistance. Starting an IV bolus (option B) may be necessary if the patient is experiencing hypovolemic shock due to excessive bleeding, but addressing the boggy uterus is the primary intervention. Getting the person out of bed to walk to the restroom (option C) is contraindicated in this situation as it does not address the immediate concern of a boggy uterus and full bladder, which can lead to further complications if not managed promptly. In an educational context, understanding the importance of prompt assessment and intervention in postpartum complications is crucial for nurses caring for postpartum patients. Recognizing signs of uterine atony and knowing the appropriate interventions can prevent serious complications such as postpartum hemorrhage. This scenario highlights the critical thinking skills and clinical judgment required in postpartum care.

Correct Answer: A

Rationale: In the postpartum period, assessing for fluid volume deficit is crucial as it can lead to serious complications. The correct answer is A) skin tenting with testing of skin turgor. Skin tenting occurs when the skin is pulled up and does not return to its normal position promptly, indicating dehydration and fluid volume deficit. Testing skin turgor is a reliable way to assess hydration status. Option B) hypertension is incorrect because fluid volume deficit typically leads to hypotension, not hypertension. Option C) bradycardia is also incorrect because in fluid volume deficit, tachycardia is more common as the body tries to compensate for decreased volume. Option D) bounding pulse is incorrect as it is associated with fluid volume excess, not deficit. Educationally, understanding the assessment findings of fluid volume deficit postpartum is essential for nurses and healthcare providers to provide timely interventions and prevent complications such as hypovolemic shock. Recognizing the signs and symptoms early can improve patient outcomes and ensure appropriate management.

Correct Answer: C

Rationale: In the context of postpartum complications, the most common reason for cracked, sore nipples is an ineffective latch (Option C). When a baby does not latch onto the breast properly, the mother may experience pain and damage to her nipples. This can occur due to incorrect positioning, shallow latch, or other breastfeeding difficulties. Option A, a hungry infant, is incorrect because nipple soreness is not typically caused by hunger, but rather by the physical act of breastfeeding. Option B, pumping, is also incorrect as pumping, when done correctly, should not cause cracked, sore nipples. Option D, lack of a supportive bra, is not the primary reason for nipple issues; while a supportive bra can help with overall comfort, it is not directly related to latch problems. Understanding the importance of a proper latch in breastfeeding is crucial for healthcare providers, lactation consultants, and new mothers. Education on correct positioning, latch techniques, and early intervention for any breastfeeding challenges can help prevent and address issues like cracked, sore nipples, ultimately promoting successful breastfeeding experiences for mothers and babies.