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

Answer and Explanation

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.

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Correct Answer is C

Explanation

The priority action in this scenario is to prevent infection. Cleansing the site with povidone-iodine can help reduce the risk of infection. Rectal temperature monitoring and administration of antibiotics may be necessary if infection is suspected, but preventing infection is the priority. Surgical closure may be necessary, but this is not an immediate concern.

A. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus. B. Observe the client's perineum for the passage of clots and the amount of bleeding C. Ask the client to lie on her back and with her knees flexed. D. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

Correct Answer is C, D, A, B

Explanation

C. Ask the client to lie on her back and with her knees flexed.

D. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

A. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.

B. Observe the client's perineum for the passage of clots and the amount of bleeding.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is C, D, A, B

Explanation

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