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A nurse is caring for a 28-year-old female client who is gravida 1 para 0 at 32 weeks of gestation in the prenatal unit.

Exhibits

The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include? Select all that apply.

A.

"I will inject this medication under your skin."

B.

"You may experience a headache after receiving this medication."

C.

"It is common for this medication to make you feel jittery."

D.

"This medication should decrease your contractions."

E.

"I'll check your reflexes frequently while you are receiving this medication."

F.

"This medication can make your heart beat faster."

G.

"This medication can increase your blood pressure."

Answer and Explanation

Correct Answer : B,C,D,E,F

B. "You may experience a headache after receiving this medication."

  • Some tocolytic medications can cause headaches as a side effect.

C. "It is common for this medication to make you feel jittery."

  • Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.

D. "This medication should decrease your contractions."

  • The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.

E. "I'll check your reflexes frequently while you are receiving this medication."

  • Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.

F. "This medication can make your heart beat faster."

  • Tocolytic medications, such as terbutaline, can increase heart rate.

These statements provide the client with a comprehensive understanding of the purpose of the medication and its potential side effects.

The incorrect statements are:

  • A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
  • G. "This medication can increase your blood pressure.": Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale

A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.

Choice B rationale

Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.

Choice C rationale

A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.

Choice D rationale

Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Based on the assessment findings, the nurse identifies that the client is at greatest risk for developing:

  1. Postpartum infection
  2. Hemorrhage

Here's the

  • Postpartum infection: The client has a history of prolonged rupture of membranes and is experiencing a moderate amount of lochia rubra, both of which increase the risk of infection. Additionally, she reports feeling weak, fatigued, and has a temperature of 38.5°C (101.3°F), which are signs of a possible infection.
  • Hemorrhage: The moderate amount of lochia rubra and a boggy fundus above the umbilicus indicate that the client may be at risk for postpartum hemorrhage. The provider's prescription for administering oxytocin if needed also suggests a concern for uterine atony, which can lead to hemorrhage.

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