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
The nurse should instruct the parents to bring the infant’s favorite blanket to the hospital.
This can provide comfort and a sense of familiarity for the infant during their hospital stay.
Choice A is incorrect because reading a story about hospitalization to an 8- month-old infant may not be developmentally appropriate.
Choice C is incorrect because parents are usually allowed to stay with their infant during hospitalization.
Choice D is incorrect because manipulating the infant’s bedtime based on the hospital’s visiting hours is not necessary.
Correct Answer is A
Explanation
This statement shows empathy and support for the client.
It also encourages the client to engage in self-care activities and promotes independence.
Choice B is not appropriate because it is a threat and does not show empathy or support for the client.
Choice C is not appropriate because it encourages the client to remain passive and does not promote independence.
Choice D is not appropriate because it is confrontational and does not show empathy or support for the client.
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