A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum.
Which of the following instructions should the nurse include?

Answer and explanation

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform? The correct answer is Choice A: Report the client's temperature elevation.

Choice A rationale:

The nurse should report the client's temperature elevation because a temperature of 37.7°C (100°F) is above the normal range for a postpartum client. A postpartum temperature greater than 100.4°F (38°C) may indicate an infection, such as endometritis or mastitis. It is essential to identify and treat infections promptly to prevent complications.

Choice B rationale:

Asking the client to empty her bladder is not the most appropriate action in this situation. While bladder distention can sometimes cause uterine displacement, the elevated temperature is a more urgent concern. The nurse should address the temperature issue first.

Choice C rationale:

Increasing IV fluids is not indicated based on the information provided. The client's temperature elevation and soft breasts are concerning, and increasing IV fluids will not address these issues. It's essential to focus on the potential infection first.

Choice D rationale:

Encouraging the client to nurse more frequently to stimulate milk production is not the priority in this scenario. While breastfeeding is essential for milk production and uterine involution, the client's elevated temperature and other findings should be addressed first.

Choice A rationale:

Placing the newborn in a prone position is not recommended during phototherapy. The infant should be placed in a supine position to maximize the surface area exposed to the phototherapy lights.

Choice B rationale:

Applying lotion to the newborn's skin can interfere with phototherapy. It's important to keep the baby's skin free from lotions or ointments to ensure the effectiveness of the treatment.

Choice C rationale:

Monitoring the newborn's blood glucose level hourly is not a standard practice during phototherapy. The primary concern during phototherapy is monitoring the infant's bilirubin levels and ensuring proper eye protection.

Choice D rationale:

Monitoring the baby's temperature while on phototherapy is essential. Phototherapy can lead to heat loss, so maintaining the baby's temperature within the normal range is crucial to prevent complications. This choice is the correct answer.