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 C
Explanation
Identification bands are an important safety measure to ensure that the newborn is properly identified and matched with the correct mother. Applying identification bands to the newborn and mother is a standard practice in all healthcare settings and is typically done immediately following delivery.
While obtaining the newborn's weight, administering IM vitamin K, and applying prophylactic eye ointment are also important interventions for a newborn, they should be done after the identification bands are applied. The order of priority for these interventions may vary depending on the healthcare facility's policies and procedures, but ensuring proper identification of the newborn is always the first step to ensure patient safety.
Correct Answer is B
Explanation
Counter pressure is a technique used to help alleviate the pain and discomfort of contractions during labor. It involves applying pressure to certain areas of the body to help relieve pain and tension. One of the most common areas for counter pressure is the lower back, as this area often experiences significant pain and discomfort during contractions.
Option A is incorrect because the top of the uterus is not an appropriate area for counter pressure during labor.
Option C is also incorrect as applying pressure between the thumb and index finger is a technique used to relieve headache pain, not labor pain.
Option D is incorrect because upward pressure on the lower abdomen is not an effective way to relieve the pain of contractions.
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