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 initial lochia post-delivery is known as lochia rubra.
Lochia is the vaginal discharge that occurs after childbirth and consists of blood, mucus, uterine tissue, and other materials from the uterus.
There are three stages of lochia: lochia rubra, lochia serosa, and lochia alba.
Lochia rubra is dark or bright red in color and lasts for about three to four days after delivery.
Choice B is not an answer because Fontanalis is not a term related to lochia.
Choice C is not an answer because lochia serosa is the second stage of lochia and occurs after lochia rubra.
Choice D is not an answer because lochia alba is the last stage of lochia and occurs after lochia serosa.
Correct Answer is A
Explanation
Allowing the child to choose an article or two of clothing that she can wear with the brace can help her feel more confident and in control of her appearance.
This can help her feel better about wearing the brace and improve her overall attitude toward the treatment.
Choice B is not the best answer because it focuses on the long-term benefits of the treatment without addressing the child’s immediate concerns and emotions.
Choice C is not the best answer because it suggests that the child should be left alone to deal with her emotions, which may not be helpful in this situation.
Choice D is not the best answer because it suggests comparing the child’s situation to others who are sicker, which may not be helpful or appropriate.
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