A nurse is caring for a client who is 42 weeks of gestation.

Exhibits

Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated

Choice A Reason:

"I will get injections of the medication once daily until my labor stops." Terbutaline is typically administered as a subcutaneous injection or orally, but the frequency can vary. It is often given as needed or on a scheduled basis, depending on the healthcare provider's instructions. However, "once daily until labor stops" is not a typical approach.

Choice B Reason:

"My blood sugar may be low while I'm on this medication." While terbutaline can affect glucose metabolism, it is more commonly associated with hyperglycemia (high blood sugar) rather than hypoglycemia (low blood sugar).

Choice C Reason:

"I will have blood tests because my potassium might decrease." Terbutaline, a beta-2 adrenergic agonist, can potentially lead to hypokalemia (a decrease in potassium levels). Monitoring potassium levels through blood tests is important during terbutaline therapy.

Choice D Reason:

"My blood pressure may increase while I'm on this medication." Terbutaline is known to cause cardiovascular side effects, but an increase in blood pressure is not a common effect. It is more associated with tachycardia (increased heart rate) and potential hypotension. Monitoring blood pressure is still important, but an increase is less likely compared to other cardiovascular effects.

A. Helping the client to the bathroom to void is not the priority in this situation. The urge to push could indicate that the baby is descending, and the nurse should be prepared for imminent delivery.

B. Observing the perineum for signs of crowning is a valid action, but having the client pant during contractions is more appropriate at this stage. It can help prevent rapid descent and potential trauma if delivery is imminent.

C. Having the client pant during the next contractions is the correct action.

Panting during contractions may slow down the urge to push and prevent rapid delivery, especially if the healthcare provider is not present or the delivery is not imminent.

D. Assisting the client into a comfortable position is important, but the priority is to manage the urge to push. Panting can be an effective technique for delaying pushing until the healthcare provider is ready for the delivery.