The postpartum home care nurse is assessing the mother, and finds her temperature to be 101.6°F. What is the most important nursing action?
1. Ask the client how often and how well the baby is nursing.
2. Determine the frequency of the mother's voiding and stooling.
3. Verify how many hours of sleep she is getting per day.
4. Assess the odor and color of the lochia and perineum.
4
Rationale:
1. A fever might indicate mastitis. Palpation of the breasts for warm or hardened areas is much better than asking about feedings, because mothers of good feeders can develop mastitis.
2. If she is voiding frequently, she might have a UTI, but the frequency of bowel movements is not related to a UTI.
3. Although it is common for new mothers to be fatigued, fatigue does not cause a fever.
4. If the lochia is malodorous, or the perineum is reddened or malodorous, an infection is present that could be causing the fever.
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