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 D
Explanation
On average, by 3 years of age, children can walk up and down stairs, one foot per step, with no support.
Choice A is incorrect because it is not developmentally appropriate for a 4-year-old child to place both feet on each step and hold on to the railing while descending stairs.
Choice B is incorrect because it is not developmentally appropriate for a 6-year-old child to place both feet on each step and hold on to the railing while descending stairs.
Choice C is incorrect because it is not developmentally appropriate for a 5-year-old child to place both feet on each step and hold on to the railing while descending stairs.
Correct Answer is C
Explanation
This is an antibiotic ointment that is applied to the eyes of newborns to prevent ophthalmia neonatorum, a serious eye infection caused by gonorrhea.
Ophthalmia neonatorum can cause blindness if left untreated and can occur even if the mother does not have symptoms of gonorrhea.
Erythromycin is the only drug approved by the FDA for this purpose and is mandated in most states.
Choice A.
Nystatin is incorrect, as this is an antifungal medication that is used to treat oral thrush or diaper rash in newborns, not eye infections.
Choice B.
Ceftriaxone is incorrect, as this is an antibiotic injection that is used to treat systemic gonorrhea infections in adults or newborns, not eye infections.
Choice D.
Ofloxacin is incorrect, as this is an antibiotic eye drop that is used to treat bacterial conjunctivitis in older children and adults, not ophthalmia neonatorum in newborns.
Therefore, choice C is the best answer to this question.
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