A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
Nervousness
Tremors
Dyspnea
Headaches
The Correct Answer is C
Choice A reason: Nervousness is a common and expected side effect of terbutaline, which is a beta-2 adrenergic agonist that stimulates the sympathetic nervous system and relaxes the uterine smooth muscle. The nurse does not need to report this finding to the provider, but can provide reassurance and comfort to the client.
Choice B reason: Tremors are also a common and expected side effect of terbutaline, as it causes increased muscle activity and shakiness. The nurse does not need to report this finding to the provider, but can monitor the client's vital signs and electrolyte levels, and advise the client to avoid caffeine and other stimulants.
Choice C reason: Dyspnea is an uncommon and serious side effect of terbutaline, as it can indicate pulmonary edema, which is a life-threatening condition where fluid accumulates in the lungs and impairs gas exchange. The nurse should report this finding to the provider immediately and prepare for interventions, such as oxygen therapy, diuretics, or discontinuation of terbutaline.
Choice D reason: Headaches are also a common and expected side effect of terbutaline, as it causes vasodilation and increased blood flow to the brain. The nurse does not need to report this finding to the provider, but can administer analgesics as prescribed, and encourage the client to rest and hydrate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as surfactant is not an antibiotic and does not treat infections. Surfactant is a substance that is naturally produced by the lungs to reduce the surface tension and prevent the alveoli from collapsing. Premature infants may have insufficient surfactant, which can cause RDS.
Choice B reason: This statement is partially true, as surfactant can help reduce episodes of periodic apnea, which is a condition where the newborn stops breathing for more than 20 seconds. However, this is not the main purpose of surfactant therapy, and other interventions, such as oxygen, ventilation, and caffeine, may be needed to treat apnea.
Choice C reason: This statement is correct, as surfactant improves the ability of the baby's lungs to exchange oxygen and carbon dioxide, which are essential for life. Surfactant therapy can improve the lung function, reduce the need for mechanical ventilation, and prevent complications, such as bronchopulmonary dysplasia and pulmonary hemorrhage.
Choice D reason: This statement is false, as surfactant does not affect the level of sedation in the newborn. Surfactant is administered through an endotracheal tube, which may require sedation to reduce discomfort and agitation. The nurse should monitor the newborn's vital signs, oxygen saturation, and pain level during and after the procedure.
Correct Answer is A
Explanation
Choice A reason: Asymmetric thigh folds is a common finding in newborns who have DDH, because the affected hip is dislocated or subluxated, causing the thigh to appear shorter and the skin folds to be uneven. The nurse should compare the number and depth of the skin folds on both sides of the groin and buttocks.
Choice B reason: Absent plantar reflexes is not a typical finding in newborns who have DDH, because it is not related to the hip joint. The plantar reflex is a normal reflex that causes the toes to curl when the sole of the foot is stroked. The nurse should assess the plantar reflex in all newborns, regardless of their hip status.
Choice C reason: Lengthened thigh on the affected side is not a usual finding in newborns who have DDH, because the opposite is true. The affected thigh is usually shorter than the unaffected thigh, due to the displacement of the femoral head from the acetabulum. The nurse should measure the length of both thighs from the anterior superior iliac spine to the medial malleolus.
Choice D reason: Inwardly turned foot on the affected side is not a specific finding in newborns who have DDH, because it can be caused by other conditions, such as metatarsus adductus or clubfoot. The inward turning of the foot is not a direct result of the hip disorder, but rather a secondary effect of the abnormal positioning of the leg. The nurse should examine the alignment and mobility of the foot and ankle.
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