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
Difficulty climbing stairs is an early sign of muscular dystrophy.
This is because the condition causes progressive muscle weakness, which can make it difficult for the child to perform physical activities that require muscle strength.
Choice A is not the best answer because high fevers and tiredness are not specific to muscular dystrophy and can be caused by many other conditions.
Choice B is not the best answer because muscular dystrophy causes muscle weakness, not increased muscle strength.
Choice C is not the best answer because respiratory infections and obesity are not specific to muscular dystrophy and can be caused by many other conditions.
Correct Answer is D
Explanation
During the first trimester of pregnancy, many women experience increased urination.
The amount of blood in your body increases during pregnancy, causing your kidneys to process extra fluid that ends up in your bladder.
Choice A, Supine hypotension, is incorrect because it refers to a condition that can occur later in pregnancy when a woman lies on her back and the weight of the uterus compresses major blood vessels.
Choice B, Heartburn, is incorrect because it is more commonly experienced later in pregnancy.
Choice C, Constipation, is incorrect because it is more commonly experienced later in pregnancy.
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