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.

Answer and Explanation

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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Correct Answer is C

Explanation

The nurse should recommend an increased fiber and fluid intake in the diet to help relieve constipation during pregnancy.
Eating more foods with fiber such as fruits, vegetables, whole grains, beans, nuts, and seeds can help fight constipation123.
Regular use of glycerine suppositories or laxatives is not recommended during pregnancy without consulting a healthcare provider first4.
Maintenance of good posture is not directly related to relieving constipation.

A. "Touch your chin to your chest, and then look up at the ceiling.". B. "Bend forward from the waist with your head and arms downward.". C. "Turn to the side, and remain in a relaxed position.". D. "Lie prone on the examination table.".

Correct Answer is B

Explanation

This is known as the Adams Forward Bend Test and is a standard screening test for scoliosis.
Choice A is incorrect because touching the chin to the chest and looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C is incorrect because turning to the side and remaining relaxed does not provide a view of the spine necessary for scoliosis screening.
Choice D is incorrect because lying prone on the examination table does not provide a view of the spine necessary for scoliosis screening.

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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?

Nursing Test Bank

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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?