The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F.
Which action should the nurse prioritize?
Continue to monitor for another hour.
Administer an antipyretic.
Assist the client in ambulation.
Notify the RN; she will notify the provider.
The Correct Answer is D
A postpartum fever is defined as a temperature greater than 100.4 degrees F (38.0 degrees C) on at least two occasions.
These fevers cannot be ignored as they can represent serious infections. The first task is to identify the source.
Choice A is not correct because continuing to monitor for another hour may delay necessary treatment.
Choice B is not correct because administering an antipyretic may only treat the symptom and not address the underlying cause of the fever.
Choice C is not correct because assisting the client in ambulation does not address the underlying cause of the fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A nurse would recommend having crackers handy at the bedside and eating a few before getting out of bed to alleviate nausea in the early morning for a pregnant woman 1.
Eating foods that don’t aggravate your stomach, such as crackers, can help limit morning sickness.
Choice A is not an answer because eating three well-balanced meals per day and limiting snacks may not help alleviate nausea.
Eating small meals can help limit morning sickness.
Choice C is not an answer because drinking a full glass of fluid at the beginning of each meal may not help alleviate nausea.
Drinking throughout the day, not just when you are thirsty, can help limit morning sickness.
Choice D is not an answer because eating a bland diet and avoiding concentrated sweets may not help alleviate nausea.
Eating foods that don’t aggravate your stomach can help limit morning sickness.
Correct Answer is A
Explanation
One of the common symptoms of autism spectrum disorder (ASD) is difficulty with social communication and interaction, which can include avoiding or not keeping eye contact.
Choice B is not an answer because sitting quietly in the caregiver’s lap during the interview is not a typical symptom of ASD.
Choice C is not an answer because smiling when shown a stuffed animal is not a typical symptom of ASD.
Choice D is not an answer because crying and running to the door when the caregiver leaves the room is not typical symptom of ASD.
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