A nurse is collecting data from a client who is receiving terbutaline to treat preterm labor.
Which of the following findings should the nurse report to the provider?
Crackles
Dizziness
Nausea
Tremors
The Correct Answer is A
A) Correct - Reporting crackles is important because they can indicate fluid retention in the lungs, which can be a serious adverse effect of terbutaline.
B) Incorrect- Dizziness is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
C) Incorrect- Nausea is a common side effect of terbutaline and might not warrant immediate reporting unless severe.
D) Incorrect- Tremors are a common side effect of terbutaline and might not warrant immediate reporting unless severe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- Foul-smelling vaginal discharge might indicate infection but is not the priority over the presence of meconium-stained amniotic fluid.
B) Correct- Fetal heart rate is important to monitor, but the presence of meconium- stained amniotic fluid has higher priority. fetal heart tones 98/min, because this indicates fetal distress and requires immediate intervention.
C) Incorrect - Amniotic fluid with meconium noted could indicate fetal hypoxia or distress, but it is not always a sign of a problem and depends on other factors such as gestational age and fetal activity.
D) Incorrect- Maternal temperature elevation might indicate infection but is not the priority over assessing the condition of the amniotic fluid and the baby.
Correct Answer is A,E,B,C,D
Explanation
Proper procedure for a heel stick includes:
A) Confirming the newborn's identity before any procedure. the nurse should confirm the newborn's identity by checking the identification band and asking the mother or caregiver to verify the name and date of birth.
E) The nurse should warm the newborn's heel by placing a warm compress or a heel warmer on the site for 3 to 5 minutes. This will increase blood flow and reduce pain.
B) Cleansing the site with an antiseptic to reduce the risk of infection. the nurse should cleanse the site with an antiseptic, such as alcohol or chlorhexidine, and let it air dry. The nurse should avoid using iodine, as it can interfere with some laboratory tests.
C) The nurse should pierce the newborn's heel with a sterile lancet, making sure to avoid the central area of the heel, where there are more nerves and bones. The nurse should use a single-use device that retracts automatically after use to prevent needlestick injuries.
D) The nurse should apply gentle pressure to the site with dry gauze to facilitate blood flow and collect the specimen in the appropriate container. The nurse should avoid squeezing or milking the site, as this can cause hemolysis or tissue damage.
E) The nurse should label the specimen with the newborn's name, date of birth, date and time of collection, and type of test. The nurse should also document the procedure in the newborn's chart, noting any difficulties or complications.
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