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

Correct Answer: A

Rationale: The correct answer is A: Monitor for signs of sepsis. Postpartum endometritis is a bacterial infection of the uterine lining that can lead to sepsis if not treated promptly. Monitoring for signs of sepsis is crucial for early detection and intervention to prevent serious complications. Option B is incorrect because breastfeeding is encouraged to promote bonding and provide nutrition. Option C is incorrect as fundal assessment is necessary to monitor uterine involution. Option D is incorrect as increasing family visiting hours is not directly related to managing postpartum endometritis.

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.

Correct Answer: C

Rationale: The correct answer is C: ineffective latch. An ineffective latch during breastfeeding can lead to cracked, sore nipples due to improper positioning and poor attachment of the baby to the breast. This can cause friction and irritation on the nipples, leading to pain and discomfort. It is crucial for the baby to have a deep latch to ensure proper milk transfer and to prevent nipple damage. Summary: A: A hungry infant may lead to more frequent feedings but not necessarily cause cracked, sore nipples. B: Pumping alone does not directly cause cracked, sore nipples; it is more related to how the baby latches during breastfeeding. D: While a lack of supportive bra may contribute to discomfort, it is not the primary reason for cracked, sore nipples.