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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A soft toy that squeaks or crackles when squeezed is a good choice for a 7- month-old infant.
At this age, babies love to explore using their mouths and hands, and they might start teething around 6 months old.
A soft toy that makes noise when squeezed can provide sensory stimulation and help with the development of fine motor skills.
A set of blocks to build a block tower is not suitable for a 7-month-old infant as they are still developing their motor skills.
A colorful crib mobile that plays music is more suitable for younger infants.
A wooden farm animal puzzle with large pieces is not suitable for a 7-month-old infant as they are still developing their cognitive and motor skills.
Correct Answer is D
Explanation
B. This is the vaccine for hepatitis B, a viral infection that can cause liver damage and cancer.
The CDC recommends that all newborns receive the first dose of this vaccine within 24 hours of birth, followed by two more doses at 1 to 2 months and 6 to 18 months of age.
Choice A.
MMR is incorrect, as this is the vaccine for measles, mumps, and rubella, which is not given at birth but at 12 to 15 months and 4 to 6 years of age.
Choice B.
Varicella is incorrect, as this is the vaccine for chickenpox, which is also not given at birth but at 12 to 15 months and 4 to 6 years of age.
Choice C.
DTaP is incorrect, as this is the vaccine for diphtheria, tetanus, and pertussis (whooping cough), which is not given at birth but at 2, 4, 6, and 15 to 18 months and 4 to 6 years of age.
Therefore, choice D is the best answer to this question.
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