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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can result in dehydration, weight loss, and ketosis.

Clinicians suspect hyperemesis gravidarum based on symptoms and can support the diagnosis by measuring urine ketones.

Choice A, Rapid plasma reagin, is a blood test used to screen for syphilis.

Choice B, Prothrombin time, is a blood test that measures how long it takes for blood to clot.

Choice D, Urine culture, may be indicated because urinary tract infection is common in pregnancy and can be associated with nausea and vomiting.

However, urine ketones would be a more speciﬁc test for hyperemesis gravidarum.

A. Creatinine 0.8 mg/dL. B. Platelet count 60,000/mm. C. Hemoglobin 148 g/dL. D. Urine protein concentration 200.

Correct Answer is B

Explanation

A platelet count of 60,000/mm is low and can be a sign of HELLP syndrome (Hemolysis Elevated Liver enzymes Low Platelet count), which is a serious complication of preeclampsia.

Choice A is not the answer because a creatinine level of 0.8 mg/dL is within the normal range.

Choice C is not the answer because a hemoglobin level of 148 g/dL is within the normal range.

Choice D is not the answer because urine protein concentration of 200 mg/dL is within the normal range for preeclampsia.

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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?

Nursing Test Bank

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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?