A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer.
Which of the following statements should the nurse tell the client?

Answer and explanation

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7°C (100°F); pulse rate 88/min; respiratory rate 18/min. Which of the following actions should the nurse perform? The correct answer is Choice A: Report the client's temperature elevation.

Choice A rationale:

The nurse should report the client's temperature elevation because a temperature of 37.7°C (100°F) is above the normal range for a postpartum client. A postpartum temperature greater than 100.4°F (38°C) may indicate an infection, such as endometritis or mastitis. It is essential to identify and treat infections promptly to prevent complications.

Choice B rationale:

Asking the client to empty her bladder is not the most appropriate action in this situation. While bladder distention can sometimes cause uterine displacement, the elevated temperature is a more urgent concern. The nurse should address the temperature issue first.

Choice C rationale:

Increasing IV fluids is not indicated based on the information provided. The client's temperature elevation and soft breasts are concerning, and increasing IV fluids will not address these issues. It's essential to focus on the potential infection first.

Choice D rationale:

Encouraging the client to nurse more frequently to stimulate milk production is not the priority in this scenario. While breastfeeding is essential for milk production and uterine involution, the client's elevated temperature and other findings should be addressed first.

The correct answer is choice d. Use a postpartum depression-screening tool with the client.

Choice A rationale:

Arranging for counseling is important for long-term support, but the first step is to accurately assess the client’s condition using a screening tool.

Choice B rationale:

Requesting a prescription for an antidepressant may be necessary, but it should follow a proper assessment and diagnosis.

Choice C rationale:

Reinforcing teaching about rest and sleep is beneficial, but it does not address the immediate need to assess the severity of the client’s symptoms.

Choice D rationale:

Using a postpartum depression-screening tool is the first step to identify the severity of the client’s symptoms and determine the appropriate course of action.