A nurse is completing a health history and assessment for a client who reports they are pregnant.
Which of the following findings is a presumptive sign of pregnancy?

Choice A rationale

Giving glucose water after feedings is not recommended for newborns undergoing phototherapy for hyperbilirubinemia. Glucose water provides no nutritional benefit, can lead to decreased breast milk intake, and does not aid in the excretion of bilirubin, which is primarily excreted through conjugated bile in stool.

Choice B rationale

Instructing the client to avoid breastfeeding during treatment for hyperbilirubinemia is incorrect. Breastfeeding should be continued and encouraged, as adequate hydration and caloric intake are crucial for promoting bowel movements, which help in the excretion of bilirubin from the body. Interruption of breastfeeding can also negatively impact milk supply.

Choice C rationale

Monitoring intake and output is critical for a newborn undergoing phototherapy. Phototherapy can increase insensible fluid losses through the skin, potentially leading to dehydration. Close monitoring of fluid intake (e.g., breastfeeding, formula) and urine/stool output ensures adequate hydration and helps assess the effectiveness of bilirubin excretion.

Choice D rationale

Applying lotions and ointments throughout phototherapy treatment is contraindicated. These products can absorb the light emitted by the phototherapy unit, leading to potential burns or uneven light distribution on the newborn's skin, thereby reducing the effectiveness of the treatment for hyperbilirubinemia.

Choice A rationale

Terbutaline is a beta-adrenergic agonist that can cause significant cardiovascular side effects, including tachycardia. A heart rate of 132/min is significantly elevated above the normal range (60-100/min) and indicates a potentially dangerous adverse effect, increasing myocardial oxygen demand and risk of cardiac complications.

Choice B rationale

Headache is a common side effect of terbutaline due to its vasodilatory effects. While uncomfortable, it is generally not life-threatening and is considered less urgent than significant cardiac or respiratory compromise. Management often involves supportive care and pain relief.

Choice C rationale

Nasal congestion is a less common and generally benign side effect of terbutaline. It is typically related to generalized vasodilation and does not pose a significant threat to maternal or fetal well-being, thus not being the priority for immediate reporting.

Choice D rationale

Tremors are a common and expected side effect of terbutaline due to its beta-agonist activity on skeletal muscle. While bothersome, they are typically self-limiting and do not indicate a severe adverse reaction requiring immediate reporting unless they are excessively severe or debilitating.