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 C
Explanation
The MSAFP test measures the levels of alpha-fetoprotein (AFP) in the mother’s body.
AFP is a protein produced by the baby during pregnancy.
Too much AFP in the mother’s body may indicate that the baby is at risk of a neural tube defect, like spina bifida.
Choice A is incorrect because this test does not screen for gestational diabetes.
Choice B is incorrect because this test does not screen for fetal maturity.
Choice D is incorrect because this test does not screen for ABO incompatibility.
Correct Answer is A
Explanation
This is a variation of the side-lying position, which is recommended for pregnant women in the third trimester to improve blood flow to the uterus and the baby12.
Sleeping on the right side with a pillow under the hip can also help relieve pressure on the inferior vena cava, a large vein that carries blood from the lower body to the heart.
Sleeping on the back can cause lightheadedness and dizziness because of this pressure, as well as increase the risk of stillbirth1.
Choice B.
Without a pillow is incorrect, as this can make sleeping on the side uncomfortable and cause back pain or leg cramps.
Choice C.
with a pillow under her shoulders is incorrect, as this can elevate the upper body and worsen heartburn, a common problem in pregnancy.
Choice D.
with a pillow under both hips is incorrect, as this can make sleeping on the back more likely, which is not advised for pregnant women in the third trimester1.
Therefore, choice A is the best answer.
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