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 D

Explanation

The size and shape of the cervix and vagina can change after childbirth, which can affect the fit and effectiveness of the diaphragm. The nurse should instruct the client to see her healthcare provider to be refitted for a new diaphragm.

Option A is incorrect because storing the diaphragm in sterile water is not necessary or recommended. The diaphragm should be cleaned with soap and water and allowed to air dry.

Option B is incorrect because the diaphragm should be removed no sooner than 6 hours after intercourse and can be left in place for up to 24 hours.

Option C is incorrect because oil-based vaginal lubricants can damage latex diaphragms, so water-based lubricants should be used instead.

A. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation. B. Use a fetal scalp electrode during labor and delivery. C. Bathe the newborn before initiating skin-to-skin contact. D. Administer a pneumococcal immunization to the newborn within 4 hr following

Correct Answer is C

Explanation

The purpose of bathing the newborn before initiating skin-to-skin contact is to decrease the risk of transmission of the virus from the mother to the newborn. Instructing the client to stop taking the antiretroviral medications at 32 weeks of gestation is incorrect as these medications should be taken throughout pregnancy to decrease the risk of transmission to the fetus.

Using a fetalscalp electrode during labor and delivery is also not an appropriate action as it increases the risk of transmission of the virus to the newborn. Administering a pneumococcal immunization to the newborn within 4 hours following birth is not specific to HIV positive newborns and is not related to preventing transmission of the virus.

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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 D

Explanation

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Correct Answer is C

Explanation

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