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?
FHR 120/min
Fasting blood glucose 75 mg/dL
Urinary output 40 ml/hr
BP 88/58 mm Hg
The Correct Answer is D
The nurse should withhold the terbutaline and report to the provider if the client's blood pressure is 88/58 mm Hg. Terbutaline can cause hypotension, and a blood pressure reading in this range indicates the client is already experiencing low blood pressure. The provider may need to adjust the medication dosage or consider an alternative medication.
The other findings are within normal ranges and would not require withholding the medication or reporting to the provider:
Fasting blood glucose of 75 mg/dL is within the normal range.
FHR of 120/min is within the normal fetal heart rate range.
Urinary output of 40 ml/hr is within normal range, although it should be monitored for any signs of decreased urine output as this could indicate dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Gestational diabetes mellitus (GDM) is a condition in which a pregnant woman develops high blood sugar levels during pregnancy. Complications of GDM can include macrosomia (a larger-than-average baby), polyhydramnios (an excessive amount of amniotic fluid), and preterm labor. One of the ways to monitor for these complications is through regular fundal height measurements. A fundal height measurement that is significantly larger than expected can indicate macrosomia or polyhydramnios, which can lead to complications during delivery.
Option B is incorrect because a fasting blood glucose of 90 mg/dL is within the normal range for a non-pregnant individual, and it is lower than the target range for a pregnant woman with GDM.
Option C is also incorrect because a fetal movement count of 12 in 1 hour is within the normal range.
Option D is incorrect because non-pitting pedal edema is a common finding in pregnancy and is not typically a cause for concern.
Correct Answer is B
Explanation
Constipation is a common problem for clients who have recently given birth, and suppositories are a common treatment option for constipation. However, suppositories are not appropriate for all clients. Certain conditions can be a contraindication to the use of suppositories, and the nurse should be aware of these conditions.
The nurse should identify that a third-degree perineal laceration is a contraindication to the use of a suppository, as it may cause further trauma to the already injured area. In this case, alternative treatments such as stool softeners or oral laxatives may be more appropriate for the client.
Option A is incorrect because although abdominal distention can be a sign of constipation, it is not a contraindication to the use of a suppository.
Option C is also incorrect because vaginal candidiasis is not a contraindication to the use of a suppository. In fact, suppositories are sometimes used to treat vaginal candidiasis.
Option D is also incorrect because afterpains are not a contraindication to the use of a suppository.
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