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?
BP 88/58 mm Hg
Urinary output 40 mL/hr
FHR 120/min.
Fasting blood glucose 75 mg/dL
The Correct Answer is A
Terbutaline is a medication that can cause serious side effects such as ante (low blood pressure).
A blood pressure reading of 88/58 mm Hg is considered low and could be a sign
of hypotension.
The nurse should withhold the medication and report this finding to the provider.
Choice B is not an answer because a urinary output of 40 mL/hr is within the
normal range.
Choice C is not an answer because a fetal heart rate (FHR) of 120/min is within the normal range.
Choice D is not an answer because a fasting blood glucose level of 75 mg/dL is
within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Bathing the newborn before initiating skin-to-skin contact is an action that the nurse should include in the plan of care for a client who is pregnant and has HIV.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.
Choice C is incorrect because instructing the client to stop taking antiretroviral medications at 32 weeks of gestation is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.
Choice D is incorrect because administering a pneumococcal immunization to the newborn within 4 hours following birth is not mentioned as an action that should be included in the plan of care for a client who is pregnant and has HIV in my sources.
Correct Answer is ["A","E"]
Explanation
The nurse should plan to immunize the client with the inactivated influenza vaccine (A) and the diphtheria-acellular pertussis vaccine (E).
The Centers for Disease Control and Prevention (CDC) recommends that pregnant women get two vaccines during every pregnancy: the inactivated flu vaccine and the Tdap vaccine.
The other vaccines listed are not recommended during pregnancy:
- The human papillomavirus vaccine is not recommended during pregnancy.
- The varicella vaccine is not recommended during pregnancy.
- The measles, mumps, and rubella vaccine is not recommended during pregnancy.
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