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 B
Explanation
Choice A reason: Missed miscarriage is not the type of abortion that the client is experiencing, because it is characterized by the absence of fetal heart activity and the retention of the products of conception in the uterus. The client would not have heavy bleeding or tissue expulsion.
Choice B reason: Incomplete miscarriage is the type of abortion that the client is experiencing, because it is characterized by the partial expulsion of the products of conception from the uterus, with some tissue remaining inside. The client would have heavy bleeding, open cervical os, and tissue present.
Choice C reason: Inevitable miscarriage is not the type of abortion that the client is experiencing, because it is characterized by the rupture of membranes and dilation of the cervical os, but no expulsion of the products of conception. The client would have moderate bleeding and cramping, but no tissue present.
Choice D reason: Complete miscarriage is not the type of abortion that the client is experiencing, because it is characterized by the complete expulsion of the products of conception from the uterus. The client would have mild bleeding and cramping, and a closed cervical os.
Correct Answer is B
Explanation
Choice A reason: Polyuria is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, diabetes, or renal impairment. A client with severe preeclampsia may have oliguria, which is a urine output of less than 500 mL in 24 hours, due to the decreased renal perfusion and function.
Choice B reason: Report of headache is an expected finding in a client with severe preeclampsia, as it can indicate increased intracranial pressure, cerebral edema, or vasospasm. A client with severe preeclampsia may also have other neurological symptoms, such as blurred vision, scotoma, photophobia, or hyperreflexia.
Choice C reason: Tachycardia is not an expected finding in a client with severe preeclampsia, as it can indicate dehydration, infection, anxiety, or fetal distress. A client with severe preeclampsia may have bradycardia, which is a heart rate of less than 60 beats per minute, due to the increased vagal tone and blood pressure.
Choice D reason: Absence of clonus is not an expected finding in a client with severe preeclampsia, as it can indicate normal or decreased neuromuscular irritability. A client with severe preeclampsia may have positive clonus, which is a rhythmic jerking of the foot when the ankle is dorsiflexed, due to the increased reflex excitability and hyperactivity.
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