A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit.

Complete the following sentence by using the list of options.
The nurse should identify that

____________

and

___________

are findings that require follow-up.

Choice A rationale

Initiating feeding on the less sore breast is generally recommended when nipples are sore or cracked. The newborn's initial suck is often the strongest and most vigorous, which can exacerbate pain and damage on an already compromised nipple. Starting on the less sore side allows for a gentler initial latch and flow.

Choice B rationale

Using breast pads with a moisture-proof lining can trap moisture against the nipples, creating a warm, damp environment that promotes bacterial or fungal growth, potentially worsening soreness or leading to infection. Air drying and absorbent, breathable pads are generally preferred for nipple healing.

Choice C rationale

Reducing feeding frequency can lead to breast engorgement, which further complicates breastfeeding and can decrease milk supply. Frequent, shorter feedings are often more comfortable for the mother and help maintain milk production while allowing the nipples to heal gradually.

Choice D rationale

Applying colostrum to the nipples after feeding is beneficial due to its immunological properties and moisturizing effect. Colostrum contains antibodies and growth factors that can promote healing, reduce inflammation, and provide a protective barrier against infection, aiding in the recovery of sore and cracked nipples.

Choice A rationale: Tocolytic medications such as terbutaline, a beta-2 adrenergic agonist, commonly cause nervous system stimulation, leading to side effects like jitteriness, tremors, and anxiety. This occurs because beta-2 receptor activation increases sympathetic nervous system activity, resulting in heightened neuromuscular excitability. These symptoms are transient and expected during therapy, reflecting systemic beta-2 receptor effects beyond uterine muscle relaxation.

Choice B rationale: Terbutaline and similar beta-2 agonist tocolytics increase heart rate by stimulating beta-adrenergic receptors in cardiac tissue. This causes positive chronotropic effects, increasing the rate of sinoatrial node firing. Tachycardia is a common adverse effect and is closely monitored as excessive cardiac stimulation can precipitate arrhythmias, especially in clients with underlying cardiac conditions.

Choice C rationale: Tocolytics like terbutaline typically do not increase blood pressure; in fact, beta-2 agonists cause vasodilation leading to decreased peripheral vascular resistance and often lower blood pressure. An increase in blood pressure is not a typical pharmacologic effect and would be unusual. Hypertensive responses are more commonly associated with other drug classes, such as alpha-agonists or corticosteroids.

Choice D rationale: The primary pharmacologic goal of tocolytics is to relax uterine smooth muscle by decreasing intracellular calcium levels, thus inhibiting contractions. Terbutaline, as a beta-2 agonist, activates adenylate cyclase increasing cAMP, which reduces contractility. Therefore, a decrease in contraction frequency and intensity is an expected therapeutic outcome.

Choice E rationale: Terbutaline is commonly administered subcutaneously, allowing for rapid absorption and onset of action. The subcutaneous route facilitates outpatient administration and easy titration of doses. Intramuscular or intravenous routes are less frequently used for this medication in preterm labor management. Patient education on injection technique and site care is essential to prevent complications.

Choice F rationale: Headaches can occur as a side effect of tocolytic therapy due to systemic vasodilation and fluid shifts. The medication-induced relaxation of vascular smooth muscle can cause mild cerebral vasodilation, leading to headaches. This side effect is generally manageable but should be monitored to differentiate from more serious adverse reactions.

Choice G rationale: Reflex monitoring is not a standard requirement for beta-2 agonist tocolytics like terbutaline. Reflex checks are more relevant for magnesium sulfate therapy, which can cause neuromuscular blockade and require frequent deep tendon reflex assessments to avoid toxicity. Therefore, frequent reflex monitoring is not indicated with terbutaline.