Nokea
The nurse is assessing a patient who is 36 hours postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply.
Correct Answer: C
Rationale: The correct answer is C because increased margins of incisional redness are indicative of a wound infection, showing an inflammatory response. This can be a sign of localized infection spreading. The other choices are incorrect as follows: A: A slight temperature increase alone is not specific to wound infection and can be attributed to other factors. B: Incisional tenderness can be expected post-surgery and does not necessarily indicate infection. D: Notably warm skin around the incision can also occur due to normal healing processes and inflammation. Therefore, only choice C directly indicates a developing wound infection.