Question

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° f (37.5° c), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm hg. which nursing action is most appropriate?

Answer 1

The nursing action appropriate for this kind of case is encouraging increased fluid intake

The rationale behind this is that around the first day of postpartum, slight dehydration usually causes a slightly elevated temperature; the nurse should also encourage increased fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may induce the risk of hemorrhage. Reassessment in vital signs every 4 hours is sufficient to evaluate the effectiveness of hydration measures. If the patient’s oral temperature exceeds 38 degrees Celsius or 100.4 degrees Fahrenheit, the nurse should request an antibiotic order since this may suggest an infection.