Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
A) Keep child warm with blankets.
B) Apply a hypothermia blanket.
C) Record temperature on nurses' notes.
D) Report findings to physician.

Question

Quizplus · Accepted Answer

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 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. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.

Seventy-Two Hours After Cardiac Surgery, a Young Child Has a Temperature