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.
The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include? Select all that apply.
"I will inject this medication under your skin."
"You may experience a headache after receiving this medication."
"It is common for this medication to make you feel jittery."
"This medication should decrease your contractions."
"I'll check your reflexes frequently while you are receiving this medication."
"This medication can make your heart beat faster."
"This medication can increase your blood pressure."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early detection and management of any potential infections.
Choice B rationale
Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage, not for routine use post-amniotomy.
Choice C rationale
Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.
Choice D rationale
Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .
Correct Answer is D
Explanation
Choice A rationale
A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.
Choice B rationale
Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.
Choice C rationale
Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.
Choice D rationale
An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.
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