A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

Hot flashes

Heart palpitations

Shortness of breath

Bradycardia

Answer and Explanation

The Correct Answer is B

A. Hot flashes: Hot flashes are not a typical adverse effect of terbutaline. Hot flashes are more commonly associated with hormonal changes, such as those that occur during menopause.

B. Heart palpitations: This is the correct answer. Terbutaline can stimulate beta-2 receptors in the heart, leading to increased heart rate and palpitations. Clients receiving terbutaline should be monitored for cardiac side effects.

C. Shortness of breath: While terbutaline is used to relax smooth muscles, it can also affect beta-2 receptors in the respiratory system. However, shortness of breath is not a common adverse effect and may indicate other respiratory issues.

D. Bradycardia: Bradycardia, or a slow heart rate, is not a typical adverse effect of terbutaline. The medication is more likely to increase heart rate due to its beta-2 adrenergic agonist properties.

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Correct Answer is A

Explanation

A. The client urinates 30 ml/hr

Effective voiding after the removal of a urinary catheter involves the ability to produce an adequate amount of urine. A urine output of 30 ml per hour is within the normal range, indicating that the client is passing urine consistently, which is a positive sign of bladder function.

B. The uterine fundus is 2 cm above the umbilicus: The position of the uterine fundus is related to postpartum uterine involution and is not a direct indicator of effective voiding. It is more relevant to assessing the progress of the uterus returning to its pre-pregnancy state.

C. The bladder is distended upon palpation: A distended bladder is a sign of urinary retention, not effective voiding. If the bladder is distended, it indicates that the client may not be emptying the bladder properly.

D. The client does not feel the urge to urinate: Lack of urge to urinate could be a sign of urinary retention or impaired bladder function. A normal and healthy bladder function includes the sensation of the urge to void when the bladder is filling.

A. Administer oxygen via a face mask B. Decrease the rate of IV fluids C. perform fetal scalp stimulation D. Elevate the client’s head

Correct Answer is A

Explanation

A. Administer oxygen via a face mask: This is the correct answer. Administering oxygen helps improve oxygenation to the fetus and is a standard intervention for late decelerations.

B. Decrease the rate of IV fluids: Decreasing IV fluids is not typically the first intervention for late decelerations. The primary goal is to improve oxygenation to the fetus, and increasing or maintaining maternal blood volume is important.

C. Perform fetal scalp stimulation: Fetal scalp stimulation is not the first-line intervention for late decelerations. It is more commonly used for assessing fetal well-being and responsiveness during the labor process.

D. Elevate the client’s head: Elevation of the client's head is not the recommended position for addressing late decelerations. Placing the client in a side-lying position is more appropriate to relieve pressure on the vena cava.

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A nurse is caring for a client who is receiving terbutaline to treat preterm labor. Which of the following findings should the nurse identify as a potential adverse effect of this medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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