A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous.
For which of the following findings should the nurse withhold the medication and report to the provider?
BP 88/58 mm Hg
Urinary output 40 mL/hr
FHR 120/min.
Fasting blood glucose 75 mg/dL
The Correct Answer is A
Terbutaline is a medication that can cause serious side effects such as ante (low blood pressure).
A blood pressure reading of 88/58 mm Hg is considered low and could be a sign
of hypotension.
The nurse should withhold the medication and report this finding to the provider.
Choice B is not an answer because a urinary output of 40 mL/hr is within the
normal range.
Choice C is not an answer because a fetal heart rate (FHR) of 120/min is within the normal range.
Choice D is not an answer because a fasting blood glucose level of 75 mg/dL is
within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should obtain a maternal serum alpha-fetoprotein (MSAFP) specimen for a client at 12 weeks of gestation.
MSAFP is a screening tool used to identify fetal neural tube defects (NTDs) such as spina bifida and anencephaly.
Elevated levels of MSAFP indicate an increased risk for NTDs, while low levels indicate an increased risk for chromosomal abnormalities such as Down syndrome.
Administering rubella vaccine (A) is contraindicated during pregnancy as it is a live vaccine and can cause fetal harm.
Administering ceftriaxone IM (B) and obtaining a blood culture (C) are not indicated based on the information provided about the client.
The client's allergy to penicillin is not relevant to the nurse's immediate action.
Correct Answer is B
Explanation
When a client is receiving magnesium sulfate by continuous IV infusion for preterm labor, it is important for the nurse to review the serum medication level to ensure that the client is receiving an appropriate dose and to monitor for signs of magnesium toxicity.
Choice A is not an answer because an indirect Coombs test is used to detect antibodies against red blood cells and is not relevant to magnesium sulfate therapy.
Choice C is not an answer because liver enzymes are not directly relevant to magnesium sulfate therapy.
Choice D is not an answer because uric acid levels are not directly relevant to magnesium sulfate therapy.
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