The nurse is caring for a client with preterm labor. Which condition should the nurse recognize as a contraindication to tocolytic therapy?
Hypotension.
Tachypnea.
Cardiac disease.
Decreased vaginal bleeding.
The Correct Answer is C
A. Some tocolytics, such as beta-adrenergic agonists (e.g., terbutaline) or calcium channel blockers (e.g., nifedipine), can lower blood pressure. While hypotension requires caution and monitoring, it is not always an absolute contraindication. The client may still receive tocolytics under close supervision if the benefits outweigh the risks, and adjustments can be made to dosage or medication selection.
B. Elevated respiratory rate may occur as a side effect of certain tocolytics, especially beta-agonists, which can cause mild respiratory stimulation. While severe tachypnea would require evaluation before administration, it is not considered a primary contraindication. Careful monitoring and supportive measures are usually sufficient.
C. This is a definitive contraindication. Tocolytic agents, particularly beta-adrenergic agonists, increase heart rate, myocardial contractility, and oxygen demand. In clients with pre-existing cardiovascular disease (e.g., arrhythmias, cardiomyopathy, or ischemic heart disease), these effects can precipitate life-threatening complications such as arrhythmias, pulmonary edema, or myocardial infarction. Calcium channel blockers may also pose risks in some cardiac conditions. Therefore, identifying cardiac disease is essential before initiating therapy, and alternative management strategies (e.g., close observation or other supportive interventions) should be considered.
D. A reduction in bleeding is a reassuring sign rather than a contraindication. Tocolytic therapy would still be appropriate if preterm labor is present, assuming no other contraindications exist.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While it is important for the UAP to report changes in the client’s respiratory status, this action does not address the immediate infection control issue related to influenza transmission. It is not the first priority in this scenario.
B. A fitted respirator (e.g., N95) is generally indicated for airborne precautions (e.g., tuberculosis), not for influenza, which is transmitted primarily through droplets. Therefore, instructing the UAP to wear a respirator is unnecessary and not evidence-based for influenza.
C. This is the most appropriate immediate action. Influenza requires droplet precautions, which include wearing a surgical or procedure mask when within close contact of the client (usually within 6 feet). Reviewing proper mask use ensures the UAP is protected and prevents the spread of infection to themselves and others. This addresses the priority safety concern.
D. Reassigning the UAP or taking over care is unnecessary if proper droplet precautions are followed. The UAP can safely assist once masked appropriately, so the nurse should first educate rather than reassign.
Correct Answer is B
Explanation
A. In conditions like a tension pneumothorax, the trachea shifts away from the affected (injured) side due to increasing pressure within the pleural space. The explanation given is inaccurate and does not correctly describe the underlying mechanism.
B. The client’s findings—severe shortness of breath, hypotension, distended neck veins, and tracheal deviation—are classic signs of a tension pneumothorax. In this condition, air enters the pleural space and becomes trapped, leading to progressively increased intrathoracic pressure. This pressure collapses the affected lung, shifts mediastinal structures (including the trachea) to the opposite side, and compresses the heart and great vessels. As a result, venous return is reduced, leading to decreased cardiac output and hypotension.
C. This statement describes a hemothorax (blood in the pleural space), not a tension pneumothorax. Additionally, compression of the lung would decrease, not increase, oxygen diffusion. Therefore, this option is incorrect both in diagnosis and physiological explanation.
D. While loss of negative pleural pressure does impair lung expansion and oxygenation, this statement is too general and does not explain the life-threatening mechanism seen in tension pneumothorax—namely, increased intrathoracic pressure and decreased cardiac output. Therefore, it is not the best explanation for this client’s condition.
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