Nokea
A client is admitted for tocolytic therapy for preterm labor. The client states, 'I'm so afraid that I'm so early. Is my baby okay? What if the drug doesn't help?' Based on the client's statement, the nurse would identify which nursing diagnosis as the priority?
- A. Anxiety
- B. Risk for Injury
- C. Impaired Gas Exchange
- D. Excess Fluid Volume
Correct Answer: A
Rationale: Based on the client's statements, the nurse would identify Anxiety as the priority nursing diagnosis because of the client's stated concern for her fetus and cessation of labor. Risk for Injury and Excess Fluid Volume would be more appropriate for a client receiving oxytocin. Impaired Gas Exchange would be appropriate if the client was experiencing adverse reactions related to the tocolytic.
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A nurse should monitor a client for which of the following adverse reactions during the administration of tocolytic therapy to prevent uterine contractions?
- A. Fatigue
- B. Diaphoresis
- C. Diplopia
- D. Hypertension
- E. Prolonged vaginal bleeding
Correct Answer: A,B,C
Rationale: A nurse should monitor a client for the following adverse reactions during tocolytic therapy to prevent uterine contractions: fatigue, flushing, headache, diplopia, diaphoresis, hypotension, depressed reflexes, and flaccid paralysis.
After teaching a group of nursing students about drugs that affect the uterus, the instructor determines that the teaching was successful when the students identify which drug as being used for cervical ripening?
- A. Terbutaline
- B. Nifedipine
- C. Dinoprostone
- D. Misoprostol
Correct Answer: C
Rationale: Dinoprostone is a cervical ripening agent, Terbutaline and nifedipine are used for tocolysis. Misoprostol is used as a uterine stimulant.
When monitoring uterine contractions of a client receiving an oxytocin infusion, the nurse should notify the primary health care provider immediately if which of the following occur?
- A. No palpable relaxation of the uterus
- B. Significant change in client's blood pressure
- C. Significant change in fetal heart rhythm
- D. Significant change in rhythm of uterine contractions
- E. Significant change in frequency of uterine contractions
Correct Answer: A,B,C,D,E
Rationale: When monitoring uterine contractions, the nurse should notify the physician immediately if any of the following occur: a significant change in fetal heart rate or rhythm; a marked change in the frequency, rate, or rhythm of uterine contractions; uterine contractions lasting longer than 60 seconds; contractions occurring more frequently than every 2 or 3 minutes; no palpable relaxation of the uterus; a marked increase or decrease in the client's blood pressure or pulse; or any significant change in the client's general condition.
A client receiving prescribed magnesium sulfate shows signs of dyspnea, tachycardia, and increased respiratory rate and rales. The nurse notices frothy sputum. Which of the following conditions should the nurse suspect?
- A. Pulmonary edema
- B. Water intoxication
- C. Renal failure
- D. Cardiac arrest
Correct Answer: A
Rationale: The client is most likely experiencing pulmonary edema. If there is an increase in respiratory rate of more than 20 respirations/min with the administration of magnesium sulfate, the nurse should assess the respiratory status for symptoms of pulmonary edema such as dyspnea, tachycardia, rales, and frothy sputum. In such cases, the primary health care provider is notified immediately because use of the drug may be discontinued or the dosage may be decreased. The danger of water intoxication is associated with oxytocin as it has an antidiuretic effect, and not with magnesium sulfate. Renal failure and cardiac arrest are not associated with magnesium sulfate.
A 30-year-old pregnant woman has been prescribed oxytocin. When assessing the client's drug regimen, the nurse understands that the client is taking vasopressors. Which of the following risks is the client most susceptible to if oxytocin is administered along with vasopressors?
- A. Anaphylactic shock
- B. Hypertension
- C. Respiratory failure
- D. Heart attack
Correct Answer: B
Rationale: Combining oxytocin with vasopressor drugs increases the risk of severe hypertension. Combining oxytocin and vasopressors does not increase the risk of heart attack or respiratory failure. Anaphylactic shock is associated with a hypersensitivity reaction and does not occur with the interaction of vasopressors and oxytocin.