The nurse is educating a client who has been menopausal for 2 years and reports physical changes and vasomotor symptoms.
What information should the nurse include when educating the client?

Nifedipine is a calcium channel blocker used off-label as a tocolytic to inhibit preterm labor. Nursing care focuses on monitoring for cardiovascular side effects, specifically hypotension, which can compromise uteroplacental perfusion and maternal stability during the management of contractions.

Choice A rationale

The goal of tocolytic therapy with nifedipine is to reduce the frequency and intensity of uterine contractions. Finding only two contractions per hour indicates the medication is achieving the desired therapeutic effect and does not require further nursing action.

Choice B rationale

While pulmonary edema is a severe complication associated with magnesium sulfate or beta-adrenergic agonists like terbutaline, it is not a common or specific side effect of nifedipine. Therefore, it is not the priority assessment finding here.

Choice C rationale

Nifedipine typically causes reflex tachycardia rather than a decreased pulse due to its vasodilatory effects. A decreased pulse is not an expected finding and does not take priority over the significant risk of hypotension associated with this drug.

Choice D rationale

Nifedipine is an antihypertensive that relaxes smooth muscle. A blood pressure of 84/60 mmHg indicates significant hypotension, which can decrease oxygen delivery to the fetus. This finding requires immediate intervention, such as fluid boluses or dosage adjustment.

Safe blood administration requires a specific sequence to ensure product viability and patient safety. The nurse must apply institutional protocols regarding the timing of blood retrieval, bedside verification, and transfusion initiation to minimize errors and prevent the waste of blood components.

Choice A rationale

Once the IV is established and consent is obtained, the nurse must retrieve the blood. Blood must be picked up only when the nurse is ready to begin the process, as it must be started quickly after leaving.

Choice B rationale

Double checking the blood with a second registered nurse occurs at the bedside immediately before the transfusion begins. This step follows the retrieval of the blood from the bank and ensures the unit matches the patient and prescription.

Choice C rationale

Priming the Y-tubing with normal saline is necessary, but the nurse cannot prime with blood until the blood has been obtained and verified at the bedside. Normal saline is the only compatible fluid for blood transfusions.

Choice D rationale

While initiation timing is critical, blood must generally be started within 30 minutes of being removed from the blood bank refrigerator, not one hour. This prevents bacterial growth and maintains the integrity of the red cells.