The postpartum nurse notes a temperature of 100.2° F four hours after a healthy newborn. What is the priority nursing action?

The postpartum nurse notes a temperature of 100.2° F four hours after a healthy newborn. What is the priority nursing action?

• A. Document the findings.
• B. Notify the obstetrician.
• C. Retake the temperature in 15 minutes.
• D. Increase hydration by encouraging oral fluids.

Answer: (D)

A mild fever in the first hours after birth is most often due to dehydration from labor and reduced oral intake. The priority step is to promote hydration, since rehydration helps normalize body temperature, improves urine output, and supports overall recovery. Encouraging oral fluids (and ensuring adequate IV fluids if intake is limited) addresses the most likely reversible cause. Documenting the finding is important for records, but it doesn’t treat the underlying issue. Retaking the temperature in a short interval isn’t the priority when hydration can be addressed immediately. Notifying the physician is indicated if the fever persists beyond 24 hours, rises higher, or is accompanied by other concerning signs (uterine tenderness, foul lochia, tachycardia, or chills with rigors), which would suggest infection.

A mild fever in the first hours after birth is most often due to dehydration from labor and reduced oral intake. The priority step is to promote hydration, since rehydration helps normalize body temperature, improves urine output, and supports overall recovery. Encouraging oral fluids (and ensuring adequate IV fluids if intake is limited) addresses the most likely reversible cause.

Documenting the finding is important for records, but it doesn’t treat the underlying issue. Retaking the temperature in a short interval isn’t the priority when hydration can be addressed immediately. Notifying the physician is indicated if the fever persists beyond 24 hours, rises higher, or is accompanied by other concerning signs (uterine tenderness, foul lochia, tachycardia, or chills with rigors), which would suggest infection.