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.
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Related Questions
Correct Answer is D
Explanation
All of the above.The nurse should include all of these signs and symptoms in the teaching as they may indicate pre-term labor.Pre-term labor occurs when regular contractions begin to open the cervix before 37 weeks of pregnancy.
Choice A is wrong because decreased fetal movement is not a normal sign of pre-term labor, but it may indicate fetal distress or other complications.
Choice B is wrong because increased vaginal discharge is not a normal sign of pre-term labor, but it may indicate infection or rupture of membranes.
Choice C is wrong because pelvic pressure is not a normal sign of pre-term labor, but it may indicate cervical dilation or descent of the fetus.
Correct Answer is C
Explanation
Assess fetal heart rate using a Doppler device.
This is because low back pain and pelvic pressure at 36 weeks of gestation may indicate preterm labor, which can affect the fetal well-being.Therefore, the nurse should assess the fetal heart rate as a priority to determine if the fetus is in distress or not.
Choice A is wrong because tocolytic medication is used to stop uterine contractions, not to relieve low back pain and pelvic pressure.Choice B is wrong because resting in a side-lying position may help with blood circulation and reduce supine hypotensive syndrome, but it does not address the possible cause of low back pain and pelvic pressure.Choice D is wrong because assessing vaginal discharge for any change may indicate infection, rupture of membranes, or cervical dilation, but it is not as urgent as assessing fetal heart rate.
Some interventions for preventing and treating low back pain and pelvic pressure during pregnancy include exercise, water-based exercise, acupuncture, osteomanipulative therapy, craniosacral therapy, and pelvic support belts.
However, these interventions should be discussed with the health care provider before starting them.
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