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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Paresthesia refers to an abnormal sensation of the skin, such as numbness, tingling, or burning.
When the nurse observes for diminished or absent sensation and numbness or tingling, they are monitoring for paresthesia.

Choice A is not correct because pain is not the symptom being monitored in this case.
Choice B is not correct because paralysis is not the symptom being monitored in this case.
Choice D is not correct because pallor refers to the paleness of the skin and is not the symptom being monitored in this case.

A. Infection. B. Potassium deficiency. C. Bleeding. D. Hyperbilirubinemia.

Correct Answer is C

Explanation

The purpose of administering vitamin K to a newborn following delivery is to prevent bleeding.
Vitamin K helps blood to clot and is essential in preventing serious bleeding in infants.

Choice A is not an answer because administering vitamin K does not prevent infection.
Choice B is not an answer because administering vitamin K does not prevent potassium deficiency.
Choice D is not an answer because administering vitamin K does not prevent hyperbilirubinemia.

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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?

Nursing Test Bank

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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?