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
Paresthesia refers to an abnormal sensation of the skin, such as numbness, tingling, or burning.
When the nurse observes for diminished or absent sensation and numbness or tingling, they are monitoring for paresthesia.
Choice A is not correct because pain is not the symptom being monitored in this case.
Choice B is not correct because paralysis is not the symptom being monitored in this case.
Choice D is not correct because pallor refers to the paleness of the skin and is not the symptom being monitored in this case.
Correct Answer is A
Explanation
Allowing the child to choose an article or two of clothing that she can wear with the brace can help her feel more confident and in control of her appearance.
This can help her feel better about wearing the brace and improve her overall attitude toward the treatment.
Choice B is not the best answer because it focuses on the long-term benefits of the treatment without addressing the child’s immediate concerns and emotions.
Choice C is not the best answer because it suggests that the child should be left alone to deal with her emotions, which may not be helpful in this situation.
Choice D is not the best answer because it suggests comparing the child’s situation to others who are sicker, which may not be helpful or appropriate.
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