The nurse is caring for a woman who had a vaginal delivery 1 hour ago. Her vital signs are T 100.4 P92 R20 BP 120/70. Based on this assessment finding, the nurse should:
Draw CBC and blood cultures
Continue to monitor the client's temperature
Report these findings immediately to the provider
Administer Tylenol STAT
The Correct Answer is B
Choice A reason: Drawing CBC and blood cultures is indicated when there is suspicion of infection, particularly with persistent fever or abnormal clinical signs. A temperature of 100.4°F within the first 24 hours postpartum is considered a normal physiological response to exertion during labor, dehydration, or breast engorgement, not necessarily infection.
Choice B reason: Monitoring the client’s temperature is appropriate because a mild elevation in temperature within the first 24 hours postpartum is common and usually resolves spontaneously. Continued monitoring ensures that if the temperature rises above 100.4°F after 24 hours or persists, infection can be promptly identified.
Choice C reason: Immediate reporting is not necessary for a single mild elevation in temperature within the first hour postpartum. It is not considered a critical finding unless accompanied by other abnormal signs.
Choice D reason: Administering Tylenol STAT is not warranted unless the client is symptomatic or the temperature is higher. Routine antipyretic administration for mild, expected postpartum temperature elevation is unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Oxytocin administration is not associated with joint pain. Its effects are primarily on uterine contractions and milk letdown.
Choice B reason: During pregnancy, immune activity is suppressed to protect the fetus. After delivery, immune rebound occurs, which can exacerbate autoimmune conditions such as rheumatoid arthritis. Increased joint pain is a normal manifestation of this rebound.
Choice C reason: Hormonal changes during breastfeeding affect lactation and menstrual cycles but are not directly responsible for joint pain.
Choice D reason: Infection would present with systemic signs such as fever, localized redness, or swelling. Isolated joint pain in a client with rheumatoid arthritis is more consistent with immune rebound rather than infection.
Correct Answer is D
Explanation
Choice A reason: Warm water increases circulation and milk flow, which worsens engorgement in non-breastfeeding mothers.
Choice B reason: Expressing milk stimulates further milk production, prolonging engorgement. This is contraindicated for mothers who are bottle feeding.
Choice C reason: A loose-fitting bra does not provide adequate support. A snug, supportive bra is recommended to minimize discomfort and reduce stimulation.
Choice D reason: Applying ice reduces swelling, inflammation, and discomfort. Cold compresses help suppress milk production and relieve engorgement in bottle-feeding mothers.
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