Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
55. A client, who is a primigravida, delivered a healthy neonate by vacuum-assisted vaginal delivery after 24 hours of labor. A nurse is performing a routine postpartum assessment 12 hours later and finds the following vital signs: blood pressure, 118/76 mm Hg; temperature, 100.8°F; pulse, 102; respirations, 20. Which interventions would be appropriate for this client? Select all that apply.
. Call the physician.
. Encourage her to increase her fluid intake.
. Assess her fundal height.
. Assess her lochia.
. Encourage her to bottle-feed.
Test-Taking Tip
This client has a risk factor for postpartum infection, a lengthy labor, and an operative delivery. Her increased temperature may be the first sign of infection.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . . .
Answer 1 is correct because calling the physician is appropriate when the client's temperature is above 100.4°F. Answer 2 is correct because encouraging her to increase fluids is an appropriate intervention after a long labor and delivery process. Some of the increased temperature may be due to dehydration. Answer 3 is correct because assessing the fundal height is a part of a routine postpartum assessment and should be performed. Answer 4 is correct because assessing the lochia is a part of a routine postpartum assessment and should be performed. Answer 5 is incorrect because there is no reason given in this scenario for encouraging the client to bottle-feed. Her increased temperature is not a reason to choose bottle feeding over breastfeeding.