Maternity Nursing: Postpartum Q 12
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2°F. Which of the following actions would be most appropriate?
A. Retake the temperature in 15 minutes.
B. Notify the physician.
C. Document the findings.
D. Increase hydration by encouraging oral fluids
Correct Answer: D. Increase hydration by encouraging oral fluids.
The mother’s temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading.
Option A: A focused physical examination is important and should include vital signs, an examination of the respiratory system, breasts, abdomen, perineum, and lower extremities. A patient with endometritis typically has a fever of 38°C or greater, tachycardia, and fundal tenderness.
Option B: The new mother should be given discharge instructions and expectations/precautions to consider once leaving the hospital. The most important information is who and where to call if she has problems or questions. She also needs details about resuming her normal activity. Instructions vary, depending on whether the mother has had a vaginal or a cesarean delivery and any comorbidities that may have been part of her care.
Option C: Although the nurse would document the findings, the most appropriate action would be to increase the hydration. The woman who has had a vaginal delivery may resume all physical activity, including using stairs, riding or driving in a car, and performing muscle-toning exercises, as long as she experiences no limiting pain or discomfort. The key counseling is to progressively resume normal activity while being mindful of the common fatigue and exhaustion experienced while caring for a newborn.