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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The newborn who is 10 hr old and has new onset tachypnea should be assessed first as this could indicate a respiratory distress, which requires immediate intervention. The other options are concerning but not as urgent as respiratory distress.
A newborn with a short frenulum and difficulty breastfeeding can be assessed after the respiratory distress is addressed.
A newborn who is 24 hr old and has not had a meconium stool should be assessed for bowel sounds and abdominal distension, but it is not as urgent as respiratory distress. A newborn who is 30 hr old and has blood-tinged discharge in her diaper can be assessed after the respiratory distress is addressed. The blood-tinged discharge could be due to the infant's mother passing her own vaginal blood to the infant or a minor vaginal laceration during delivery.
Correct Answer is A
Explanation
Hypovolemic shock is caused by a significant loss of blood or fluids, resulting in decreased tissue perfusion and oxygenation. Cool, clammy skin is a classic symptom of hypovolemic shock, indicating that the body is redirecting blood flow to vital organs. A respiratory rate of18/min is within normal limits. Bounding pulses are associated with conditions such as hyperthyroidism or aortic regurgitation. A urinary output of 30 mL/hr is low, but it is not necessarily indicative of hypovolemic shock on its own.
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