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 D

Explanation

“You should place your baby on her back when sleeping to decrease the risk of SIDS.” According to Mayo Clinic, placing a baby on their back to sleep is one of the most important measures that can be taken to help protect a child from SIDS1.
Choice A is incorrect because there is no evidence that SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines.
Choice B is incorrect because SIDS rates have actually decreased dramatically since the American Academy of Pediatrics issued its safe sleep recommendations in 19922.
Choice C is incorrect because while sleep apnea may contribute to breathing problems, it is not considered the main cause of SIDS1.

A. Regular use of glycerine suppositories. B. Maintenance of good posture. C. Increased fiber and fluid in the diet. D. Regular use of a laxative.

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.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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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?