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A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?
- A. Drowsiness and bradycardia.
- B. Depressed reflexes and increased respirations.
- C. Tachycardia and a feeling of nervousness.
- D. A flushed, warm feeling and a dry mouth.
Correct Answer: C
Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.
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A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct Answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.
In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
- A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
- B. Growth and development have been abnormal since birth.
- C. Muscular strength can be regained with physical exercise and therapy.
- D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
- A. Graph the daily weight for the past week.
- B. Decrease IV flow rate.
- C. Assess bilateral lung sounds.
- D. Restrict intake of oral fluids.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?
- A. Schedule a visit with the healthcare provider today.
- B. Verify the compatibility of the administered Rho(D) immune globulin.
- C. Encourage the client to increase her intake of oral fluids.
- D. Instruct the client to maintain bedrest for 24 hours.
Correct Answer: C
Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.
The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant's head-to-heel length
- B. Observe the infant for sunsetting eyes
- C. Palpate the anterior fontanel for tension and bulging
- D. Plot the measurement on the infant's growth chart
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.