A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol.
For which of the following findings should the nurse withhold the medication?
Uric acid 7.5 mg/dL (2.7 to 7.3 mg/dL).
Heart rate 54/min.
FHR 112/min.
BUN 23 mg/dL (10 to 20 mg/dL).
The Correct Answer is B
Choice A rationale
Uric acid levels in preeclampsia can be elevated due to decreased renal clearance and increased production, often exceeding the normal range of 2.7 to 7.3 mg/dL. A value of 7.5 mg/dL is slightly elevated, which is a common finding in preeclampsia and does not typically contraindicate the administration of labetalol, an antihypertensive medication. It reflects disease progression but does not pose an immediate risk regarding medication administration.
Choice B rationale
Labetalol is a beta-blocker that reduces heart rate and blood pressure. A heart rate of 54/min is below the normal adult resting heart rate range (typically 60-100 beats/min) and indicates bradycardia. Administering labetalol to a client with pre-existing bradycardia could further depress the heart rate, potentially leading to symptomatic bradycardia, decreased cardiac output, and inadequate tissue perfusion, thus requiring the nurse to withhold the medication.
Choice C rationale
A fetal heart rate (FHR) of 112/min is within the normal range for a fetus (typically 110-160 beats/min). While labetalol can rarely cause fetal bradycardia, a baseline FHR of 112/min does not contraindicate its administration. The primary concern with labetalol in preeclampsia is the maternal hemodynamic response, and this FHR value does not indicate an immediate fetal distress that would preclude the medication.
Choice D rationale
A BUN level of 23 mg/dL is slightly elevated above the normal range of 10 to 20 mg/dL, often seen in preeclampsia due to impaired renal function. While this indicates renal involvement, it does not contraindicate the administration of labetalol. Labetalol is primarily metabolized by the liver, and while caution is advised in renal impairment, this BUN level alone does not warrant withholding the medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Prior to IUD insertion, screening for sexually transmitted infections (STIs) is crucial to prevent the introduction of pathogens into the upper reproductive tract. An untreated STI, particularly chlamydia or gonorrhea, can lead to pelvic inflammatory disease (PID) when an IUD is placed, as the device might facilitate the ascent of bacteria.
Choice B rationale
The duration of effectiveness for intrauterine devices varies depending on the type. Hormonal IUDs typically last for 3 to 8 years, while copper IUDs can remain effective for up to 10 years. Therefore, the statement that the device must be replaced every 2 years is incorrect and misleading for most available IUDs.
Choice C rationale
Irregular spotting and changes in menstrual bleeding patterns are common side effects during the initial months following IUD placement, particularly with hormonal IUDs. This is due to the local endometrial effects of progesterone release or the inflammatory reaction induced by copper, as the uterus adapts to the foreign body.
Choice D rationale
There is no medical contraindication to using tampons with an IUD. The IUD resides in the uterus, while tampons are inserted into the vaginal canal. There is no physical interaction or risk of dislodgement of the IUD by tampon use. Clients can continue their preferred menstrual hygiene products.
Choice E rationale
Informed consent is a fundamental ethical and legal requirement before any medical procedure, including IUD insertion. The client must be provided with comprehensive information regarding the procedure, including its benefits, risks, alternatives, and potential side effects, to make an autonomous and voluntary decision.
Correct Answer is B
Explanation
Choice A rationale
Variable decelerations are typically caused by umbilical cord compression, which can occur in various obstetric scenarios but are not a specific expected finding for placenta previa. In placenta previa, the primary issue is placental implantation over or near the cervical os, leading to distinct clinical manifestations.
Choice B rationale
Painless vaginal bleeding is the hallmark clinical finding of placenta previa. This occurs because the placenta is implanted in the lower uterine segment, potentially covering the internal cervical os. As the cervix effaces or dilates, the placenta separates from the uterine wall, leading to bleeding without the associated pain of uterine contractions.
Choice C rationale
A rigid abdomen is a classic sign of abruptio placentae, where the placenta prematurely detaches from the uterine wall. This causes internal bleeding and uterine spasm, leading to a board-like, tender abdomen, which is distinct from the typical presentation of placenta previa.
Choice D rationale
Uterine tachysystole, characterized by excessive uterine contractions, is a common finding in conditions like abruptio placentae or during labor induction. It is not typically associated with placenta previa, where the primary concern is the placental position and the risk of hemorrhage rather than abnormal contraction patterns.
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