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 A
Explanation
“The most common drug used by teenagers is alcohol.” According to the National Institute on Drug Abuse (NIDA), alcohol is one of the most commonly used drugs among teenagers.
Choice B is incorrect because tobacco use can have harmful effects on teenagers.
Choice C is incorrect because using substances as a release from pressure is not a healthy coping mechanism.
Choice D is incorrect because not every teenager experiments with substances.
Correct Answer is C
Explanation
Elevated levels of MSAFP may indicate that the baby is at risk of a neural tube defect, like spina bifida.
However, further testing is required to confirm the results and determine the cause of the elevated levels.
Choice A is incorrect because low levels of MSAFP may indicate a risk for Down syndrome, not elevated levels.
Choice B is incorrect because while elevated levels of MSAFP may indicate a risk for neural tube defects, further testing is required to confirm this.
Choice D is incorrect because while repeating the test may be necessary, further testing beyond just repeating the MSAFP screening may also be required.
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