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 D
Explanation
Compartment syndrome is a condition where increased pressure within a muscle compartment causes muscle and nerve damage along with pain.
One of the symptoms of compartment syndrome is severe pain that increases with the stretching of muscles.
Choice A is not correct because blue-looking nail beds on the toes are not a symptom of compartment syndrome.
Choice B is not correct because a weak femoral pulse is not a symptom of compartment syndrome.
Choice C is not correct because the inability to plantarflex the foot is not a symptom of compartment syndrome.
Correct Answer is C
Explanation
Symmetry of the hips is a normal finding and is not a sign of developmental hip dysplasia.
Choice A is not correct because limited abduction of the affected hip is a sign of developmental hip dysplasia.
Choice B is not correct because it includes all the other choices.
Choice D is not correct because shortening of the femur can be a sign of developmental hip dysplasia.
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