A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously.Which of the following adverse effects is the priority for the nurse to report to the provider?

Heart rate 132/min.

Report of headache.

Nasal congestion.

Tremors.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.

Choice B rationale

While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.

Choice C rationale

Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.

Choice D rationale

Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

Preterm Labor

Preterm labor refers to labor that begins before 37 weeks of gestation. The key findings associated with preterm labor are:

Cervical effacement and dilation: The client is 100% effaced and 2 cm dilated.
Regular uterine contractions: The client is experiencing contractions every 3 minutes, lasting 60 seconds.
Bloody show: The presence of bloody mucus discharge is another sign of preterm labor.
Low backache: The client reports cramping and low back pain.

Preterm Prelabor Rupture of Membranes (PPROM)

PPROM refers to the rupture of membranes before labor begins and before 37 weeks of gestation. The key findings associated with PPROM are:

Vaginal discharge: The client reported urinary leakage earlier, which could be misinterpreted as amniotic fluid leakage. Clear mucus discharge can also be a sign of ruptured membranes.

A. Check the client's temperature frequently following the procedure. B. Insert misoprostol rectally every 2 hours following the procedure. C. Obtain a biophysical profile during the procedure. D. Perform effleurage to the client's abdomen during the procedure.

Correct Answer is A

Explanation

Choice A rationale

Checking the client's temperature frequently following the procedure is crucial. An amniotomy increases the risk of infection, so frequent monitoring of temperature helps in early detection and management of any potential infections.

Choice B rationale

Inserting misoprostol rectally every 2 hours following the procedure is not recommended. Misoprostol is a medication used for inducing labor or controlling postpartum hemorrhage, not for routine use post-amniotomy.

Choice C rationale

Obtaining a biophysical profile during the procedure is not relevant. A biophysical profile is an assessment of fetal well-being and is not typically performed during amniotomy.

Choice D rationale

Performing effleurage to the client's abdomen during the procedure is not necessary. Effleurage is a massage technique used for pain relief during labor, but it is not related to the management of an amniotomy. .

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A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously.Which of the following adverse effects is the priority for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A"}}

Explanation

A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse.Which of the following statements should the charge nurse include during the discussion?

Correct Answer is A

Explanation

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