A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4 °F (38 °C). What action by the nurse is best?
A.
Encourage the woman to drink plenty of fluids.
B.
Document the findings and notify the provider.
C.
Have the woman cough and deep breathe.
D.
Prepare to administer acetaminophen (Tylenol).
ANS: A
Dehydration and exertion often cause a transient increase in body temperature up to 100.4 °F (38 °C) during the first 24 hours after birth. Increased fluids usually help restore normothermia. The nurse should first encourage the woman to drink increased fluids. The findings should be documented, but the provider does not need to be notified. Coughing and deep breathing are good strategies to relieve atelectasis, but this is not the most common cause of elevated temperature after childbirth. The patient may or may not want acetaminophen, but drinking more fluids is the priority over giving an antipyretic medication.
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