A nurse is assessing a client who is in pre-term labor and has received one dose of terbutaline subcutaneously.
Which of the following findings should the nurse report to the provider?
Heart rate of 110/min
Blood pressure of 150/90 mm Hg
Blood glucose of 90 mg/dL
Temperature of 37°C (98.6°F)
The Correct Answer is B
Blood pressure of 150/90 mmHg. This is because terbutaline can cause elevated blood pressure as a side effect.
The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.
Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline. Terbutaline can cause fast or pounding heartbeats as a common side effect.
Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals. Terbutaline can cause transient hyperglycemia (high blood sugar) as a serious side effect, but this is not the case here.
Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being. Terbutaline does not cause fever or hypothermia as a side effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Instruct the client to empty her bladder.This is because a full bladder can interfere with the insertion of the needle and increase the risk of injury to the bladder or the uterus.Emptying the bladder also reduces discomfort during the procedure.
Choice A is wrong because administering tocolytic medication to stop contractions is not necessary before amniocentesis.Tocolytic medication can have side effects and should only be used when there is a clear indication of preterm labor.
Choice C is wrong because obtaining informed consent from the client is not a nursing action, but a medical one.The nurse can assist in providing information and answering questions, but the final consent should be obtained by the doctor who will perform the procedure.
Choice D is wrong because monitoring fetal heart rate and activity is not a specific action before amniocentesis, but a routine part of prenatal care.Fetal heart rate and activity can be affected by many factors, such as maternal position, fetal sleep cycle, or maternal blood sugar level.
Monitoring them before amniocentesis does not provide any useful information for the procedure.
Correct Answer is C
Explanation
Magnesium sulfate is a drug that is used to prevent seizures associated with pre-eclampsia and to stop preterm labor.However, it can also cause adverse effects such as respiratory depression, which is a condition where the breathing rate becomes too slow and shallow.
Respiratory depression can be life-threatening for both the mother and the baby, so the nurse should monitor the client’s respiratory rate and oxygen saturation closely.
Choice A is wrong because magnesium sulfate can cause hypotension, not hypertension.Hypotension is low blood pressure, which can lead to dizziness, fainting, and shock.
Choice B is wrong because magnesium sulfate can cause hyporeflexia, not hyperreflexia.Hyporeflexia is a reduced or absent reflex response, which can indicate magnesium toxicity.
The nurse should check the client’s deep tendon reflexes regularly and stop the infusion if they are absent.
Choice D is wrong because magnesium sulfate can cause bradycardia, not tachycardia.
Bradycardia is a slow heart rate, which can reduce the blood flow to vital organs.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.