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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A shrill cry may indicate distress but isn't specifically related to hypoglycemia in newborns.
Choice B rationale
Weak peripheral pulses are more commonly associated with circulatory or cardiac issues rather than hypoglycemia.
Choice C rationale
Yellowish skin suggests jaundice, which is due to elevated bilirubin levels, not hypoglycemia.
Choice D rationale
Hypotonia, or decreased muscle tone, can be a sign of hypoglycemia in newborns, indicating a need to check blood glucose levels.
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.
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