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 B
Explanation
When people with bulimia nervosa frequently engage in self-induced vomiting, the gastric acids in their vomit can damage the tooth enamel.
This is called dental erosion and can create “bulimia teeth”.
Choice A, Food is rapidly ingested without proper mastication, is incorrect because it does not directly relate to tooth enamel deterioration.
Choice C, Poor dental and oral hygiene leads to dental caries, is incorrect because it refers to a different dental issue.
Choice D, Purging causes the depletion of dietary calcium, is incorrect because it does not directly relate to tooth enamel deterioration.
Correct Answer is C
Explanation
The MSAFP test measures the levels of alpha-fetoprotein (AFP) in the mother’s body.
AFP is a protein produced by the baby during pregnancy.
Too much AFP in the mother’s body may indicate that the baby is at risk of a neural tube defect, like spina bifida.
Choice A is incorrect because this test does not screen for gestational diabetes.
Choice B is incorrect because this test does not screen for fetal maturity.
Choice D is incorrect because this test does not screen for ABO incompatibility.
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