A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?

FHR 120/min

Fasting blood glucose 75 mg/dL

Urinary output 40 ml/hr

BP 88/58 mm Hg

Answer and Explanation

The Correct Answer is D

The nurse should withhold the terbutaline and report to the provider if the client's blood pressure is 88/58 mm Hg. Terbutaline can cause hypotension, and a blood pressure reading in this range indicates the client is already experiencing low blood pressure. The provider may need to adjust the medication dosage or consider an alternative medication.

The other findings are within normal ranges and would not require withholding the medication or reporting to the provider:

Fasting blood glucose of 75 mg/dL is within the normal range.

FHR of 120/min is within the normal fetal heart rate range.

Urinary output of 40 ml/hr is within normal range, although it should be monitored for any signs of decreased urine output as this could indicate dehydration.

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Correct Answer is B

Explanation

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that can be spread through contact with contaminated objects or people. Contact isolation precautions are used to prevent the spread of infectious organisms that are spread by direct or indirect contact. This includes wearing gloves and a gown when entering the client's room and removing them before leaving the room, as well as using dedicated equipment and ensuring proper disinfection of surfaces.

Droplet isolation precautions are used to prevent the spread of organisms that are spread by droplets from coughing, sneezing, or talking. Airborne isolation precautions are used to prevent the spread of organisms that can remain suspended in the air and travel long distances, such as tuberculosis. Protective environment precautions are used for clients who have compromised immune systems, such as those who have undergone a bone marrow transplant, and involve using special air filtration systems and limiting visitors to reduce the risk of infection.

A. The client has a fundal height of 38 cm B. The client has a fasting blood glucose of 90 mg/dL. C. The client reports 12 fetal movements in 1 hr. D. The client has non pitting pedal edema.

Correct Answer is A

Explanation

Gestational diabetes mellitus (GDM) is a condition in which a pregnant woman develops high blood sugar levels during pregnancy. Complications of GDM can include macrosomia (a larger-than-average baby), polyhydramnios (an excessive amount of amniotic fluid), and preterm labor. One of the ways to monitor for these complications is through regular fundal height measurements. A fundal height measurement that is significantly larger than expected can indicate macrosomia or polyhydramnios, which can lead to complications during delivery.

Option B is incorrect because a fasting blood glucose of 90 mg/dL is within the normal range for a non-pregnant individual, and it is lower than the target range for a pregnant woman with GDM.

Option C is also incorrect because a fetal movement count of 12 in 1 hour is within the normal range.

Option D is incorrect because non-pitting pedal edema is a common finding in pregnancy and is not typically a cause for concern.

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A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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