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 A
Explanation
One of the common symptoms of autism spectrum disorder (ASD) is difficulty with social communication and interaction, which can include avoiding or not keeping eye contact.
Choice B is not an answer because sitting quietly in the caregiver’s lap during the interview is not a typical symptom of ASD.
Choice C is not an answer because smiling when shown a stuffed animal is not a typical symptom of ASD.
Choice D is not an answer because crying and running to the door when the caregiver leaves the room is not typical symptom of ASD.
Correct Answer is B
Explanation
A. Lateral incisors are present:At 6 months, infants typically begin teething, but the lateral incisors usually do not appear until around 9 to 13 months. The first teeth to emerge are usually the lower central incisors.
B. Posterior fontanel is closed:The posterior fontanel, or the soft spot at the back of the baby's head, typically closes by 2 to 3 months of age. Therefore, it is expected to be closed by the time the infant is 6 months old.
C. Infant's birth weight is tripled:By 6 months, infants generally double their birth weight. Tripling of birth weight is more commonly expected by the end of the first year.
D. Infant sits well without support:Most infants begin to sit without support around 7 to 9 months. At 6 months, they may sit with some support but are not yet expected to sit well independently.
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