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

Magnesium sulfate is a medication commonly used to treat preeclampsia, a pregnancy-related condition characterized by high blood pressure and damage to other organ systems, such as the kidneys. However, magnesium sulfate can also cause adverse reactions, and the nurse should be aware of these reactions.

The nurse should recognize that a urine output of 20 mL/hr is a manifestation of an adverse reaction to magnesium sulfate, as magnesium sulfate can cause decreased urine output, which can lead to dehydration and electrolyte imbalances. The nurse should promptly report this finding to the provider, as it may require immediate intervention.

Option A is incorrect because hypertension is a symptom of preeclampsia, not an adverse reaction to magnesium sulfate.

Option B is also incorrect because hyperglycemia is not an adverse reaction to magnesium sulfate.

Option C is also incorrect because a respiratory rate of 16/min is within the normal range.

A. Three fetal movements perceived by the client in a 20-min testing period B. No late decelerations in the fetal heart rate noted with three uterine contractions of 60 seconds in duration within a 10-min testing period C. An increase in fetal heart rate to 150/min above the baseline 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client

Correct Answer is D

Explanation

The nonstress test is a screening tool that assesses fetal well-being. It is performed by monitoring the fetal heart rate (FHR) and uterine contractions (UC) while the client is at rest. The test is considered reactive if there are two or more accelerations of the FHR that reach a certain level above the baseline and last for at least 15 seconds over a 20-min period.

The presence of irregular contractions that are not felt by the client is a finding that is concerning because it could be a sign of uterine hyperstimulation, which can lead to fetal distress. Further diagnostic testing may be needed to assess fetal well-being in this situation.

Option A indicates that the client felt fetal movements during the testing period. This is a reassuring finding because fetal movements are a sign of fetal well-being.

Option B indicates that there were no late decelerations in the FHR with uterine contractions. This is a reassuring finding because late decelerations are a sign of fetal compromise.

Option C indicates that there was an acceleration of the FHR in response to fetal movement. This is a reassuring finding because it indicates that the fetus is capable of responding to stimuli.

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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

A nurse is caring for a client who is at 30 weeks of gestation and receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

Correct Answer is D

Explanation

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?

Correct Answer is D

Explanation

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