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 priority intervention for a newly-admitted client who has acute osteomyelitis is antibiotic therapy.
Choice A is incorrect because antipyretic therapy is not the priority intervention.
Choice C is incorrect because optimal nutrition and hydration are not the priority intervention.
Choice D is incorrect because surgical debridement of necrotic tissue is not the priority intervention.
Correct Answer is A
Explanation
Pregnant vegans should ensure they are getting enough vitamin B12, which is essential for the development of the infant’s nervous system.
Vitamin B12 is found almost exclusively in animal products, so vegans should consume fortified foods such as cereals or take a supplement to ensure they are getting enough of this important nutrient.
Choice B, Milk, and cheese, is not correct because it is not vegan.
Choice C, Nuts, seeds, and chocolate, is not correct because it does not address the need for vitamin B12.
Choice D, Carrots, sweet potatoes, and mangoes, is not correct because it does not address the need for vitamin B12.
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