A nurse is caring for a female client, 32 years old, in the postpartum unit following an emergency cesarean birth.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

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

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and

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.

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.

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.