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 A
Explanation
A. The nurse should monitor for chorioamnionitis, which is an infection of the amniotic sac and fluid.
The other choices are not potential complications of gonorrhea:
B. Vaginal laceration during birth is not a complication of gonorrhea.
C. Oligohydramnios is not a complication of gonorrhea.
D. Excessive bleeding after birth is not a complication of gonorrhea.
Correct Answer is B
Explanation
Nägele’s Rule is a method for estimating the expected date of delivery (EDD) or confinement (EDC).
It involves adding seven days and one year, and subtracting three months, from the first day of the last menstrual period (LMP)1.
Using this rule, if the first day of the client’s last menstrual period was July 28th, then adding seven days would be August 4th.
Subtracting three months would be May 4th.
Adding one year would be May 4th of the following year.
Therefore, the nurse should document May 5th as the client’s expected delivery date.
Choice A is incorrect because April 21st is too early according to Nägele’s Rule calculation.
Choice C is incorrect because May 21st is too late according to Nägele’s Rule calculation.
Choice D is incorrect because April 4th is too early according to Nägele’s Rule calculation.
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