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
It is important to ensure the safety of the newborn, and in this situation, the adolescent mother is putting the newborn at risk by leaving him unattended while feeding. Offering to take the newborn to the nursery allows him to finish feeding in a safe environment while also allowing the nurse to assess his feeding and ensure he is receiving adequate nutrition. It is important to provide education to the mother on safe feeding practices, but at this moment, ensuring the safety of the newborn is the priority.
Correct Answer is B
Explanation
Increased urination, or polyuria, is a common clinical finding in clients with hyperglycemia. High levels of glucose in the blood can cause the kidneys to work harder to filter out the excess glucose, resulting in increased urine output.
Option A, dizziness, is a nonspecific symptom and can occur for a variety of reasons, including hypoglycemia, hyperglycemia, or dehydration.
Option C, sweating, is also a nonspecific symptom and can occur for a variety of reasons, including hypoglycemia, hyperglycemia, or anxiety.
Option D, double vision, is a symptom that can occur in severe cases of hyperglycemia or diabetic ketoacidosis. However, it is not a common or early symptom of hyperglycemia.
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