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?
Dyspnea
Headaches
Nervousness
Tremors
The Correct Answer is A
Choice A reason:
Dyspnea: Dyspnea, or difficulty breathing, is a serious adverse effect that should be reported immediately. Terbutaline can cause pulmonary edema, a condition where fluid accumulates in the lungs, leading to severe breathing difficulties. This side effect is critical and requires prompt medical attention to prevent further complications.
Choice B reason:
Headaches: While headaches are a common side effect of terbutaline, they are generally not considered severe enough to require immediate reporting unless they are persistent or unusually intense. Headaches can be managed with over-the-counter pain relief and do not typically indicate a serious problem.
Choice C reason:
Nervousness: Nervousness is another common side effect of terbutaline. It is usually mild and does not require immediate medical intervention. However, if the nervousness is severe or accompanied by other symptoms, it should be discussed with a healthcare provider.
Choice D reason:
Tremors: Tremors are a known side effect of terbutaline and are usually not severe. They occur due to the medication’s action on the nervous system. While they can be bothersome, they are not typically dangerous and do not require urgent reporting unless they are severe or persistent.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Covering the cord with a sterile, moist saline dressing is important to prevent the cord from drying out and to reduce the risk of infection. However, this is not the immediate priority. The primary concern is to relieve pressure on the cord to ensure adequate blood flow and oxygen to the fetus.
Choice B Reason:
Placing the client in the knee-chest position helps to relieve pressure on the umbilical cord by using gravity to shift the fetus away from the pelvis. This is a crucial step, but it should be done after manually relieving the pressure on the cord with a gloved hand.
Choice C Reason:
Preparing the client for an immediate birth is necessary if the cord prolapse cannot be resolved quickly. However, the first action should be to manually relieve the pressure on the cord to prevent fetal hypoxia while preparations for delivery are made
Choice D Reason:
Inserting a gloved hand into the vagina to relieve pressure on the cord is the immediate priority. This action directly addresses the risk of compromised blood flow and oxygen supply to the fetus, which is the most urgent concern in the case of a cord prolapse.
Correct Answer is A
Explanation
Choice A reason:
The indirect Coombs test is used to detect Rh-positive antibodies in the mother’s blood. This test is crucial for Rh-negative mothers who have given birth to Rh-positive infants. It helps determine if the mother has been sensitized to Rh-positive blood and has developed antibodies against it. If these antibodies are present, they can cross the placenta in future pregnancies and attack the red blood cells of an Rh-positive fetus, leading to hemolytic disease of the newborn.
Choice B reason:
The statement “It determines the presence of maternal antibodies in the newborn’s blood” is incorrect. The indirect Coombs test is performed on the mother’s blood, not the newborn’s. It screens for antibodies that could potentially harm the fetus in future pregnancies. The direct Coombs test, on the other hand, is used to detect antibodies that are already attached to the newborn’s red blood cells.
Choice C reason:
The statement “It detects Rh-negative antibodies in the newborn’s blood” is incorrect. The indirect Coombs test does not detect Rh-negative antibodies in the newborn’s blood. Instead, it identifies antibodies in the mother’s blood that could react against Rh-positive red blood cells. This test helps in assessing the risk of hemolytic disease in future pregnancies.
Choice D reason:
The statement “It determines if kernicterus will occur in the newborn” is incorrect. Kernicterus is a severe form of jaundice caused by high levels of bilirubin in the blood. While the Coombs test can help identify hemolytic disease, which can lead to jaundice, it does not directly determine the risk of kernicterus. The primary purpose of the indirect Coombs test is to detect antibodies that could cause hemolytic disease in future pregnancies.
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