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

Correct Answer: B

Rationale: In the context of postpartum wound infection, the correct nursing intervention to include in the plan of care is to assess for REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation of wound edges). This is the correct answer because assessing for REEDA provides crucial information about the status of the wound infection, guiding appropriate treatment and interventions. Option A is incorrect because reassuring the postpartum person that the infection will resolve without antibiotics is not evidence-based practice and can lead to complications if the infection worsens. Option C is incorrect as waiting until the temperature is 99.0° F to call the healthcare provider may delay necessary treatment for the wound infection. Option D is incorrect as vigorous scrubbing of the incision with soap and water can further aggravate the wound and increase the risk of infection. In an educational context, it is important for nurses to understand the significance of proper wound assessment techniques like REEDA in identifying and managing postpartum wound infections promptly. Teaching nursing students to prioritize assessment skills and evidence-based interventions in the care of postpartum individuals can improve patient outcomes and prevent complications.

Correct Answer: B

Rationale: In postpartum hemorrhage (PPH), a late (secondary) PPH typically occurs between 24 hours and up to 6 weeks after delivery. The correct answer, B) is caused by subinvolution of the uterus, is characteristic of late PPH. Subinvolution refers to the delayed return of the uterus to its normal non-pregnant size, leading to persistent bleeding. Option A) is incorrect because PPH that occurs within the first 24 hours is considered an early PPH. Option C) is incorrect as PPH can occur after both vaginal and cesarean births. Option D) is incorrect as Methergine is a common medication used to treat PPH, including cases of subinvolution. Educationally, understanding the timing and causes of different types of PPH is crucial for healthcare providers working in obstetrics. Recognizing the characteristics of late PPH, such as subinvolution, helps in prompt identification and appropriate management to prevent serious complications like hemorrhagic shock.

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.