A nurse assesses a woman's temperature 6 hours after a vaginal ...

[audragclark]

A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4 F (38 C). What action by the nurse is best?
 
  A.
  Encourage the woman to drink plenty of fluids.
  B.
  Document the findings and notify the provider.
  C.
  Have the woman cough and deep breathe.
  D.
  Prepare to administer acetaminophen (Tylenol).

Question 2

A nurse has brought a newborn to his mother's room. What action by the nurse takes priority?
 
  A.
  Asking the mother her full name and her birth date
  B.
  Comparing the baby to a photograph on the mother's bedside table
  C.
  Having the mother wash her hands before taking the baby
  D.
  Matching the information on the mother's and baby's wristbands

[amy.lauersdorf90]

Answer to Question 1

ANS: A
Dehydration and exertion often cause a transient increase in body temperature up to 100.4 F (38 C) during the first 24 hours after birth. Increased fluids usually help restore normothermia. The nurse should first encourage the woman to drink increased fluids. The findings should be documented, but the provider does not need to be notified. Coughing and deep breathing are good strategies to relieve atelectasis, but this is not the most common cause of elevated temperature after childbirth. The patient may or may not want acetaminophen, but drinking more fluids is the priority over giving an antipyretic medication.

Answer to Question 2

ANS: D
The safety and security of the infant must be maintained at all times. When bringing the baby to the mother, the nurse ensures proper identification by comparing and matching information on both the mother's and the baby's identification band. Having the mother wash her hands before taking the baby is a good practice to reduce the risk of infection, but security takes priority.