A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
Nervousness
Tremors
Dyspnea
Headaches
The Correct Answer is C
Choice A reason: Nervousness is a common and expected side effect of terbutaline, which is a beta-2 adrenergic agonist that stimulates the sympathetic nervous system and relaxes the uterine smooth muscle. The nurse does not need to report this finding to the provider, but can provide reassurance and comfort to the client.
Choice B reason: Tremors are also a common and expected side effect of terbutaline, as it causes increased muscle activity and shakiness. The nurse does not need to report this finding to the provider, but can monitor the client's vital signs and electrolyte levels, and advise the client to avoid caffeine and other stimulants.
Choice C reason: Dyspnea is an uncommon and serious side effect of terbutaline, as it can indicate pulmonary edema, which is a life-threatening condition where fluid accumulates in the lungs and impairs gas exchange. The nurse should report this finding to the provider immediately and prepare for interventions, such as oxygen therapy, diuretics, or discontinuation of terbutaline.
Choice D reason: Headaches are also a common and expected side effect of terbutaline, as it causes vasodilation and increased blood flow to the brain. The nurse does not need to report this finding to the provider, but can administer analgesics as prescribed, and encourage the client to rest and hydrate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Initiation of pushing is not an appropriate nursing action, as it can increase the bleeding and the risk of placental separation, which can cause fetal hypoxia, hemorrhage, or shock. Pushing is contraindicated in clients with placenta previa, which is a condition where the placenta covers the cervical opening and can cause painless, bright red bleeding in the third trimester.
Choice B reason: Examination to determine cervical status is not an appropriate nursing action, as it can cause trauma and perforation of the placenta, which can lead to severe bleeding and infection. Examination is contraindicated in clients with placenta previa, unless it is confirmed by ultrasound that the placenta is not low-lying or covering the cervix.
Choice C reason: Preparation for cesarean birth is an appropriate nursing action, as it is the preferred mode of delivery for clients with placenta previa, especially if the bleeding is heavy, the fetus is mature, or the fetal distress is present. Cesarean birth can prevent the complications of placenta previa, such as fetal hypoxia, hemorrhage, or shock.
Choice D reason: A magnesium sulfate infusion is not an appropriate nursing action, as it is a drug that prevents seizures and lowers the blood pressure in clients with severe preeclampsia, which is a hypertensive disorder of pregnancy. Magnesium sulfate is not indicated for clients with placenta previa, unless they also have severe preeclampsia or eclampsia.
Correct Answer is A
Explanation
Choice A reason: The mother applying lotion to the newborn's skin requires intervention by the nurse, because it can interfere with the effectiveness of phototherapy and increase the risk of thermal injury. The nurse should instruct the mother to avoid using any lotions, creams, or oils on the newborn's skin during phototherapy.
Choice B reason: The newborn's stools increasing in number does not require intervention by the nurse, because it is a normal and expected outcome of phototherapy. Phototherapy can increase the breakdown and excretion of bilirubin, which can result in more frequent and loose stools.
Choice C reason: A pink rash appearing on the newborn's trunk does not require intervention by the nurse, because it is a common and harmless side effect of phototherapy. The rash usually disappears within a few days after phototherapy is discontinued.
Choice D reason: The newborn's eyes being covered with a mask does not require intervention by the nurse, because it is a standard and essential precaution for phototherapy. The mask protects the newborn's eyes from the harmful effects of the light, such as corneal damage or retinal injury.
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