Puerperal Infection Practice Exam

EXPLANATION

✔Correct answer:

Development of endometritis. Nurse Alex should be most vigilant about the development of endometritis in Maria. Endometritis is an infection of the uterine lining that is a significant postpartum complication, especially in women who have experienced prolonged labor and premature rupture of membranes (PROM). The prolonged rupture of membranes (over 18-24 hours) allows bacteria to ascend from the vagina into the uterine cavity, increasing the risk of infection. Additionally, the extended duration of labor can further heighten this risk as it may lead to increased exposure to potential pathogens.

During labor, the protective barrier provided by the amniotic sac is compromised once the membranes rupture. This disruption allows microorganisms from the lower genital tract to enter the uterine cavity. If the exposure to these pathogens is prolonged, as it was in Maria's case, the risk of developing an infection like endometritis rises significantly. The infection typically manifests with symptoms such as uterine tenderness, fever, foul-smelling lochia, and elevated white blood cell counts.

Think of the uterus as a normally sealed container of food. When the seal (the amniotic sac) is intact, bacteria can't get inside. But once the seal is broken, and if the container is left open for too long (prolonged rupture of membranes), bacteria can enter and spoil the food (cause infection).

To effectively manage and prevent the development of endometritis, Nurse Alex should focus on the following interventions and considerations:

• Monitor vital signs frequently, paying close attention to temperature and heart rate as signs of infection.
• Assess the patient's lochia (postpartum vaginal discharge) for color, odor, and amount, noting any signs of infection.
• Encourage good perineal hygiene to minimize the risk of ascending infections.
• Administer antibiotics as prescribed to treat or prevent endometritis.
• Educate the patient on signs and symptoms of infection and the importance of reporting any changes immediately.

✘Incorrect answer options:

Onset of endometriosis. Endometriosis is a condition characterized by the growth of endometrial tissue outside the uterus, typically associated with chronic pelvic pain and infertility, not with postpartum infections. It is not a condition that would acutely develop in the immediate postpartum period, especially following labor and membrane rupture.

Inflammation of the fallopian tubes (salpingitis). Salpingitis is an infection or inflammation of the fallopian tubes, typically linked to pelvic inflammatory disease (PID). While it is a serious condition, it is not directly related to the specific postpartum scenario described, where the primary concern is the risk of infection in the uterine lining due to prolonged labor and ruptured membranes.

Presence of pelvic thrombophlebitis. Pelvic thrombophlebitis involves inflammation and clot formation in the pelvic veins, which can occur postpartum but is less directly linked to prolonged labor and premature rupture of membranes than endometritis. It is a secondary concern compared to the immediate risk of uterine infection in this scenario.

EXPLANATION

✔Correct answer:

Breast injury resulting from overdistention, milk stasis, and cracked nipples. Mastitis is an infection of the breast tissue that primarily occurs in breastfeeding women. The most common cause of mastitis is milk stasis, which can occur when the milk is not properly drained from the breast, leading to overdistention. This can be caused by infrequent breastfeeding, improper latch, or blocked milk ducts. Cracked nipples can serve as entry points for bacteria, allowing infection to develop. Therefore, the primary predisposing factor for mastitis that Nurse Lisa should emphasize is the combination of breast injury due to milk stasis, overdistention, and cracked nipples.

Mastitis typically begins with milk stasis, where the milk is not effectively removed from the breast. When milk accumulates, it can cause distention of the milk ducts and surrounding tissue, leading to localized pressure and potential tissue damage. This can result in cracks or fissures in the nipple, creating an entry point for bacteria, often Staphylococcus aureus, which is commonly found on the skin. The bacteria can then enter the breast tissue, leading to an inflammatory response. The body's immune response to the infection results in symptoms like redness, warmth, pain, and swelling in the affected area. If untreated, mastitis can progress to form an abscess, a localized collection of pus that may require surgical intervention.

Think of the breast like a water balloon. If too much water (milk) builds up without being released, the balloon becomes overdistended and can develop weak spots (cracks), making it easier for bacteria to enter and cause an infection.

Nurse Lisa should educate the mother on effective breastfeeding techniques, including ensuring the baby is latching correctly and feeding frequently to prevent milk stasis. She should also discuss the importance of good nipple care to prevent cracking, such as using nipple creams or ensuring the nipples are kept clean and dry.

• Encourage regular breastfeeding or pumping to ensure proper milk drainage.
• Educate the mother on signs of poor latch and how to correct it.
• Recommend nipple care strategies to prevent cracks, such as using lanolin-based creams.
• Instruct the mother on recognizing early signs of mastitis, such as localized breast pain, redness, and warmth.
• If mastitis is present, discuss the need for possible antibiotic therapy and continued breastfeeding to promote milk flow.

✘Incorrect answer options:

Infection spreading from hospital sources, affecting the lactiferous glands and ducts. While hospital-acquired infections are possible, mastitis is typically caused by bacteria that are already present on the mother's skin or in the infant's mouth. The condition usually results from milk stasis rather than an external infection spreading from hospital sources.

Infection that occurs randomly, targeting the connective tissue around the glands. Mastitis does not typically occur randomly; it is usually linked to specific factors like milk stasis and nipple trauma. While the infection involves breast tissue, including the connective tissue, it is not a random event but rather a result of conditions like overdistention and cracked nipples.

Temporary urinary retention from reduced perception of the need to void. This option is unrelated to mastitis. Urinary retention may occur postpartum but does not predispose someone to mastitis. The primary concern with urinary retention would be its impact on the urinary system, not the development of breast infections.

EXPLANATION

✔Correct answer:

“I need to stop breastfeeding until this condition clears up.” This statement indicates that Karen might need additional teaching. It is a common misconception that breastfeeding should be stopped during mastitis, but continuing to breastfeed is actually important. Mastitis is an infection of the breast tissue that commonly occurs during breastfeeding, and maintaining regular breastfeeding or pumping helps prevent milk stasis, which can exacerbate the condition. Continuing to breastfeed also helps to clear the infection faster because it ensures the breast is being emptied, reducing the risk of further complications like abscess formation.

Mastitis typically develops due to milk stasis or bacterial entry into the breast tissue through a cracked nipple. The inflammation can lead to symptoms such as breast pain, redness, warmth, and fever. If breastfeeding is stopped, milk stasis can worsen, leading to an increased risk of abscess formation and prolonged infection. Furthermore, the infant is not at risk from the infection, as the milk remains safe to consume.

Think of mastitis like a clogged drain. If you stop using the drain, the clog can worsen and create more problems. But if you keep the water (milk) flowing, it helps clear out the blockage (infection).

To ensure that Karen properly understands how to manage mastitis, Nurse Samantha should focus on the following teaching points:

• Reassure Karen that she can and should continue breastfeeding or pumping, as this will help resolve the infection.
• Instruct her on proper breastfeeding techniques and positions to prevent milk stasis and reduce nipple trauma.
• Advise her to apply warm compresses to the affected breast before feeding to help with milk flow and reduce pain.
• Recommend frequent breastfeeding or pumping, starting with the affected breast to ensure it is emptied fully.
• Educate Karen on the importance of completing her antibiotic course as prescribed, even if symptoms improve.

✘Incorrect answer options:

“I’ll take antibiotics, and I should start feeling better within 24-48 hours.” This statement is correct. Antibiotics are a key part of the treatment for mastitis, and patients typically start to feel better within 24-48 hours after beginning the medication.

“I can use pain relievers to help manage the discomfort.” This statement is also correct. Pain relievers, such as ibuprofen or acetaminophen, can be used to manage the pain and inflammation associated with mastitis.

“Wearing a supportive bra will help ease the discomfort.” This is another accurate statement. Wearing a supportive, non-restrictive bra can provide comfort and support to the breasts, which can help alleviate some of the pain caused by mastitis.

EXPLANATION

✔Correct answer:

The character and amount of lochia. The patient’s elevated temperature, tender and enlarged uterus, and delayed uterine descent are key signs of a potential postpartum infection, such as endometritis. Endometritis is an inflammation of the inner lining of the uterus, typically caused by an infection, and is a common postpartum complication.

The character (color, odor, and consistency) and amount of lochia (postpartum vaginal discharge) are crucial indicators of infection. Lochia changes can suggest abnormal recovery or infection, particularly if the lochia has a foul odor, is excessive, or changes to a purulent (pus-like) discharge. This assessment helps Nurse Emily gather vital information to identify or rule out an infection, which is important for initiating timely treatment and preventing complications like sepsis.

Consider lochia as a recovery report card from the uterus. If the report card suddenly shows failing grades (like a foul smell or unusual amount), it signals that something might be wrong with the healing process, prompting further investigation.

After assessing the lochia, Nurse Emily should also monitor the patient for other signs of infection, such as chills, increased heart rate, and abdominal pain. Depending on findings, she may need to notify the healthcare provider, who may prescribe antibiotics if an infection is confirmed. Continuous monitoring of the lochia, uterine size, and patient temperature is essential to track the progression of the condition.

• Document lochia findings in detail, including color, amount, and odor.
• Administer prescribed antibiotics if an infection is confirmed.
• Encourage the patient to report any additional symptoms such as fever or foul-smelling discharge.
• Provide education on proper perineal hygiene to prevent infection.

✘Incorrect answer options:

The condition of the breasts. While breast condition (e.g., signs of mastitis) is important in postpartum assessment, it is not directly related to the symptoms presented in this scenario (elevated temperature, tender uterus, and abnormal uterine size). These symptoms are more indicative of uterine complications rather than issues with breastfeeding or breast infections.

The appearance of the incision site. The incision site is crucial to assess in postpartum patients who have had a cesarean section. However, the symptoms described are more suggestive of a uterine infection rather than a surgical site infection, particularly since the uterus remains large and tender.

The urine output and characteristics. Monitoring urine output is important for overall patient assessment, especially for hydration status and kidney function. However, in the context of a tender, enlarged uterus and abnormal lochia, the character of lochia is a more direct indicator of a potential uterine infection.

EXPLANATION

✔Correct answer:

Continue breastfeeding or pumping to maintain milk flow. Nurse Carla should instruct Sarah to continue breastfeeding or pumping even though she has mastitis. This is because maintaining milk flow is crucial for resolving the infection. Breastfeeding or pumping helps to empty the breast, reducing milk stasis, which is a contributing factor to mastitis. It also helps prevent complications such as abscess formation. Stopping breastfeeding can lead to further milk accumulation and exacerbate the infection.

Mastitis occurs when milk stasis or bacterial infection leads to inflammation of the breast tissue. Continuation of breastfeeding helps to keep the milk ducts clear, thereby promoting healing. The bacteria causing mastitis are usually not harmful to the baby, and breastfeeding does not need to be discontinued. In fact, frequent feeding or pumping can help clear the infection more quickly.

Imagine trying to unclog a pipe by keeping water flowing through it. If you stop the flow, the clog could get worse. Similarly, continuing to breastfeed or pump keeps the milk flowing and helps clear out the infection.

When educating Sarah about managing mastitis, Nurse Carla should emphasize the following key instructions:

• Encourage Sarah to continue breastfeeding or pumping, starting with the affected breast to ensure it is emptied fully.
• Advise applying warm compresses before breastfeeding to help with milk flow and reduce discomfort.
• Recommend gentle massage of the affected area during feeding to help clear blocked ducts.
• Ensure Sarah understands the importance of completing the full course of antibiotics, even if she feels better before the medication is finished.
• Suggest wearing a supportive, well-fitting bra to provide comfort and reduce pain.

✘Incorrect answer options:

Discontinue breastfeeding from the affected breast until the infection resolves. This is incorrect because stopping breastfeeding can worsen milk stasis, leading to more severe infection or abscess formation. The correct approach is to continue breastfeeding or pumping to ensure the breast is emptied regularly.

Apply cold compresses to the affected breast to reduce swelling. While cold compresses can be used to relieve pain, warm compresses are typically recommended before feeding to promote milk flow. Cold compresses may be applied after feeding to reduce swelling, but this is not the most critical instruction for managing mastitis.

Stop taking antibiotics once symptoms improve. This is incorrect because it can lead to incomplete treatment of the infection and potential relapse. It is essential for Sarah to complete the entire course of antibiotics as prescribed, even if symptoms improve.

EXPLANATION

✔Correct answer:

Sitting in a semi-Fowler's position. Nurse Mia should consider placing the patient in a semi-Fowler's position to help manage endometritis. Endometritis is an infection of the uterine lining (endometrium) that commonly occurs postpartum. Placing the patient in a semi-Fowler's position facilitates drainage of lochia and infectious material from the uterus by using gravity, thereby reducing the risk of the infection spreading and promoting healing.

By elevating the head of the bed to about 30 to 45 degrees (semi-Fowler's position), the lochia (postpartum discharge) and any purulent material are encouraged to flow out of the uterus, preventing the accumulation of infected material inside the uterus. This position also helps in alleviating discomfort and promoting overall patient comfort.

Imagine you have a cup with some liquid at the bottom (infected lochia). Tilting the cup slightly (semi-Fowler's position) allows the liquid to flow out more easily, rather than letting it pool at the bottom.

Along with positioning, Nurse Mia should monitor the patient's temperature, pain levels, and lochia characteristics (amount, color, odor), as these can indicate the severity of the infection. The patient may also receive antibiotics as part of the treatment, and adequate hydration and rest should be encouraged.

✘Incorrect answer options:

Lying flat on her back (supine). The supine position is not ideal for managing endometritis because it can prevent proper drainage of lochia and infectious material, potentially worsening the infection.

Positioned on her left side. While positioning on the left side can be beneficial in other conditions, such as in managing blood pressure or improving venous return, it does not specifically aid in draining the uterine cavity in cases of endometritis.

Placed in the Trendelenburg position. The Trendelenburg position, where the body is tilted with the head lower than the feet, would counteract gravity and encourage the pooling of infected material in the uterus, making it an inappropriate choice for managing endometritis.