A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

Dyspnea

Headaches

Nervousness

Tremors

Answer and Explanation

The Correct Answer is A

Choice A reason:

Dyspnea: Dyspnea, or difficulty breathing, is a serious adverse effect that should be reported immediately. Terbutaline can cause pulmonary edema, a condition where fluid accumulates in the lungs, leading to severe breathing difficulties. This side effect is critical and requires prompt medical attention to prevent further complications.

Choice B reason:

Headaches: While headaches are a common side effect of terbutaline, they are generally not considered severe enough to require immediate reporting unless they are persistent or unusually intense. Headaches can be managed with over-the-counter pain relief and do not typically indicate a serious problem.

Choice C reason:

Nervousness: Nervousness is another common side effect of terbutaline. It is usually mild and does not require immediate medical intervention. However, if the nervousness is severe or accompanied by other symptoms, it should be discussed with a healthcare provider.

Choice D reason:

Tremors: Tremors are a known side effect of terbutaline and are usually not severe. They occur due to the medication’s action on the nervous system. While they can be bothersome, they are not typically dangerous and do not require urgent reporting unless they are severe or persistent.

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Correct Answer is B

Explanation

Choice A reason:

Assessing maternal blood glucose is important in various clinical scenarios, such as managing diabetes during pregnancy. However, it is not directly related to the immediate issue of magnesium sulfate toxicity. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min is a critical sign that requires immediate intervention to prevent further complications.

Choice B reason:

Discontinuing the magnesium infusion is the priority intervention. Magnesium sulfate toxicity can lead to severe respiratory depression, hypotension, and loss of deep tendon reflexes. A respiratory rate of 10/min indicates significant respiratory depression, which can be life-threatening. Stopping the infusion immediately helps to prevent further accumulation of magnesium in the body and allows for the administration of the antidote, calcium gluconate, if necessary.

Choice C reason:

Preparing for an emergency cesarean birth is a critical intervention in cases of fetal distress or other obstetric emergencies. However, in this scenario, the immediate concern is the client’s respiratory depression due to magnesium sulfate toxicity. Addressing the respiratory issue takes precedence to stabilize the client before considering any surgical interventions.

Choice D reason:

Placing the client in Trendelenburg position is typically used to treat hypotension or shock by promoting venous return to the heart. While it can be beneficial in certain situations, it does not address the primary issue of respiratory depression caused by magnesium sulfate toxicity. The priority is to discontinue the magnesium infusion and manage the respiratory depression.

A. Ask the client if she has considered harming her newborn. B. Anticipate a prescription by the provider for an antidepressant. C. Reinforce postpartum and newborn care discharge teaching. D. Assist the family to identify proper use of positive coping skills in family crises.

Correct Answer is A

Explanation

Choice A Reason:

The priority action is to assess the safety of both the client and the newborn. Asking the client if she has considered harming her newborn is crucial to determine if there is an immediate risk of harm. This question helps identify any potential danger and allows for immediate intervention if necessary. Ensuring the safety of the mother and baby is the top priority in managing postpartum depression.

Choice B Reason:

Anticipating a prescription for an antidepressant is important, but it is not the immediate priority. Medication can be part of the treatment plan for postpartum depression, but first, it is essential to assess the client’s safety and risk of harm to herself or her newborn.

Choice C Reason:

Reinforcing postpartum and newborn care discharge teaching is beneficial for the client’s overall understanding and management of her condition. However, it does not address the immediate concern of potential harm to the newborn or the severity of the client’s depressive symptoms

Choice D Reason:

Assisting the family to identify proper use of positive coping skills is a valuable long-term strategy for managing postpartum depression. However, the immediate priority is to assess the client’s safety and ensure there is no risk of harm to herself or her newborn.

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A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?

Correct Answer is B

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is A

Explanation

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