Seventy-two hours after cardiac surgery, a young child has a temperature of 37.7? C (101? F). The nurse should:
a. Keep the child warm with blankets.
b. Apply a hypothermia blanket.
c. Record the temperature on nurses' notes.
d. Report findings to physician.
ANS: D
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7? C (100? F) as part of the inflammatory response to tissue trauma. If the temperature is higher or an elevated temperature continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. A hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation.
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