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 observes Brittny during meal times and for 2 hours after eating to monitor for purging behaviors.
Choice A is incorrect because building a trusting relationship with the patient is important but not the primary reason for observing the patient during meal times and for 2 hours after eating.
Choice C is incorrect because teaching about nutrition is important but not the primary reason for observing the patient during meal times and for 2 hours after eating.
Choice D is incorrect because taking a break with the patient is not the primary reason for observing the patient during meal times and for 2 hours after eating.
Correct Answer is B
Explanation
The nurse should include in their teaching that the client should increase their folic acid intake during pregnancy.
Choice A is incorrect because a pregnant woman at 8 weeks of gestation does not need to increase her daily calorie intake by 750 calories.
Choice C is incorrect because a pregnant woman should not limit her iron intake during her first trimester.
Choice D is incorrect because a pregnant woman should not stop taking her prenatal vitamin if she experiences nausea.
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