Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7┬░C (100┬░F); pulse rate 88/min; respiratory rate 18/min.Which of the following actions should the nurse perform?
Correct answer
A
Rationale
The correct answer is A: Report the client's temperature elevation. This is the priority action as it indicates a potential infection, which can be life-threatening for the client and baby. Reporting allows for timely intervention. B is incorrect as it does not address the underlying issue. C is not indicated without further assessment. D is incorrect as it does not address the temperature elevation. Focusing on milk supply is not the priority.