A nurse is assisting with the care of a client who is at 34 weeks of gestation and received a dose of nifedipine 2 hr ago. For which of the following therapeutic effects should the nurse monitor?
An increase in platelet count
A decrease in blood pressure
A decrease in FHR
An increase in urinary output
The Correct Answer is B
A. Nifedipine does not directly affect platelet count.
B. Nifedipine is a calcium channel blocker used to lower blood pressure. Monitoring for a decrease in blood pressure is essential.
C. Nifedipine does not typically cause a significant decrease in fetal heart rate (FHR).
D. While nifedipine may impact urinary output indirectly through blood pressure regulation, it is not the primary therapeutic effect to monitor.
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Related Questions
Correct Answer is C
Explanation
A. Homans' sign is a test for deep vein thrombosis and is not a normal postpartum finding.
B. Full, firm breasts typically occur a few days after delivery when milk production begins, not at 20 hours postpartum.
C. A firm fundus at the midline is an expected finding in the immediate postpartum period, indicating that the uterus is contracting and involuting properly.
D. Lochia serosa (pinkish-brown discharge) is a normal finding around 3 to 10 days postpartum, but it is not typically present at 20 hours postpartum.
Correct Answer is D
Explanation
A. Nausea is a common side effect of terbutaline, but it is not typically a cause for concern. It may be managed with measures like taking the medication with food.
B. Tremors are a known side effect of terbutaline. While they may be uncomfortable for the client, they are an expected side effect and not necessarily indicative of a problem requiring immediate intervention.
C. Dizziness can occur as a side effect of terbutaline. It is important to monitor the client for this, but it is not typically a severe side effect that requires immediate reporting to the provider.
D. Crackles (also known as rales) in the lungs suggest the possibility of fluid accumulation, which could be a sign of pulmonary edema. This is a serious concern and should be reported to the provider promptly, as it may require a change in treatment or further evaluation.
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