Seventy-two hours after cardiac surgery, a young child has a temperature of 38.4° C (101.1° F). What action should the nurse perform?
a. Report findings to the practitioner.
b. Apply a hypothermia blanket.
c. Keep the child warm with blankets.
d. Record the temperature on the assessment flow sheet.
ANS: A
In the first 24 to 48 hours after surgery, the body temperature may increase to 37.8° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or fever continues after this period, it is most likely a sign of an infection, and immediate investigation is indicated. A hypothermia blanket is not indicated for this level of temperature. Blankets should be removed from the child to keep the temperature from increasing. The temperature should be recorded, but the practitioner must be notified for evaluation.
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