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A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
- A. Fasting blood glucose 75 mg/dL
- B. Blood pressure 88/58 mmHg
- C. Urinary output 40 mL/hr
- D. FHR 120/min
Correct Answer: B
Rationale: Correct Answer: B (Blood pressure 88/58 mmHg)
Rationale: Terbutaline is a tocolytic medication used to inhibit preterm labor contractions by relaxing uterine smooth muscle. A low blood pressure of 88/58 mmHg indicates hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased perfusion to the fetus and maternal organs, warranting withholding the medication and notifying the provider for further evaluation and management.
Summary of Incorrect Choices:
A: Fasting blood glucose 75 mg/dL - Normal blood glucose level, not a concerning finding related to terbutaline administration.
C: Urinary output 40 mL/hr - Normal urinary output, not a concerning finding related to terbutaline administration.
D: FHR 120/min - Normal fetal heart rate, not a concerning finding related to terbutaline administration.
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A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy. This of the following statements by the client indicates an understanding of the teaching.
- A. “I will count baby’s lacks every other day.
- B. “I will alternate the arm use to check my blood pressure
- C. I will check my urine for protein daily
- D. I will consume 50 grams of protein daily
Correct Answer: C
Rationale: The correct answer is C: "I will check my urine for protein daily." This is the correct answer because monitoring urine for protein is crucial in managing preeclampsia. Proteinuria is a key marker for worsening preeclampsia as it indicates kidney damage. By checking urine daily, the client can detect early signs of deterioration and seek medical help promptly.
Answers A, B, and D are incorrect because they do not directly relate to monitoring preeclampsia. Counting baby's kicks (A) and alternating arm use for blood pressure checks (B) are important but not as critical as monitoring proteinuria. Consuming 50 grams of protein daily (D) is beneficial for overall health during pregnancy but does not specifically address the management of preeclampsia.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.
A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, White Vaginal Discharge
- B. Urinary Frequency
- C. Vulva Lesions
- D. Malodorous Discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous Discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, typically presenting with a foul-smelling, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis due to inflammation and infection of the vaginal mucosa. Other choices are incorrect because: A) Thick, White Vaginal Discharge is more indicative of a yeast infection; B) Urinary Frequency is not a common symptom of trichomoniasis; C) Vulva Lesions are not typically associated with trichomoniasis at 20 weeks of gestation.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: Rationale: Choice C is correct because ensuring the newborn's eyes are closed beneath the shield during phototherapy prevents potential eye damage from the bright light. Closing the eyes protects the delicate eye tissues from exposure to the intense light. This action is crucial in preventing eye injury and promoting the safety and well-being of the newborn.
Incorrect Choices:
A: Applying lotion to the skin can intensify the effects of the light and should be avoided.
B: Giving glucose water is unnecessary and not related to phototherapy.
D: Dressing the newborn in clothing can interfere with the effectiveness of the light therapy.