A nurse is assessing a client who is in pre-term labor and has received one dose of terbutaline subcutaneously.
Which of the following findings should the nurse report to the provider?
Heart rate of 110/min
Blood pressure of 150/90 mm Hg
Blood glucose of 90 mg/dL
Temperature of 37°C (98.6°F)
The Correct Answer is B
Blood pressure of 150/90 mmHg. This is because terbutaline can cause elevated blood pressure as a side effect.
The nurse should report this finding to the provider as it may indicate hypertension or a hypertensive crisis.
Choice A is wrong because a heart rate of 110/min is not abnormal for a person who has received terbutaline. Terbutaline can cause fast or pounding heartbeats as a common side effect.
Choice C is wrong because a blood glucose of 90 mg/dL is within the normal range of 70-130 mg/dL before meals. Terbutaline can cause transient hyperglycemia (high blood sugar) as a serious side effect, but this is not the case here.
Choice D is wrong because a temperature of 37°C (98.6°F) is normal for a human being. Terbutaline does not cause fever or hypothermia as a side effect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I will call my doctor if I have more than four contractions in an hour.” This statement indicates that the client understands the signs of preterm labor and when to seek medical attention.Preterm labor is defined as having regular contractions and cervical changes before 37 weeks of gestation.More than four contractions in an hour may indicate that preterm labor is occurring and requires prompt evaluation.
Choice A is wrong because drinking at least eight glasses of water every day is not a specific instruction for preventing preterm labor.However, dehydration can trigger contractions and should be avoided.
Choice B is wrong because lying on the back with a pillow under the knees can reduce blood flow to the uterus and the baby.This position can also increase the risk of blood clots in the legs.A better position is lying on the left side, which improves circulation and reduces pressure on the cervix.
Choice C is wrong because avoiding sexual intercourse until reaching term is not necessary for most women with a history of preterm labor.Sexual activity does not cause preterm labor or premature rupture of membranes (PROM).However, some women may be advised to abstain from sex if they have certain conditions, such as placenta previa or a short cervix.
Correct Answer is A
Explanation
Ultrasound.
An ultrasound can help determine the gestational age, fetal growth, placental location, and amniotic fluid volume of the fetus.
These factors can affect the risk of pre-term labor and delivery.
An ultrasound can also detect cervical changes that may indicate pre-term labor.
Choice B is wrong because a blood count is not specific for pre-term labor.
It may be done to check for anemia, infection, or other conditions that may affect the pregnancy, but it does not directly assess the risk of pre-term labor.
Choice C is wrong because a urine culture is not specific for pre-term labor.
It may be done to check for urinary tract infection, which can cause pre-term labor, but it does not directly assess the risk of pre-term labor.
Choice D is wrong because an amniocentesis is not usually done for pre-term labor.
It may be done to check for fetal lung maturity, chromosomal abnormalities, or infections, but it is an invasive procedure that carries some risks and complications.
It does not directly assess the risk of pre-term labor.
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