Nokea
The client is admitted with a diagnosis of preterm labor at 32 weeks gestation. The physician orders a tocolytic. The nurse should monitor for which complication?
- A. Fetal hypoglycemia
- B. Maternal tachycardia
- C. Fetal macrosomia
- D. Maternal hypokalemia
Correct Answer: B
Rationale: Tocolytics (e.g. nifedipine terbutaline) can cause maternal tachycardia as a side effect due to their effects on smooth muscle relaxation or beta-adrenergic stimulation. Fetal hypoglycemia macrosomia and maternal hypokalemia are not typical complications.
You may also like to solve these questions
A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?
- A. Start the child on solid food.
- B. Nurse the child more frequently during this growth spurt.
- C. Provide supplements for the child between breastfeeding so you will have enough milk.
- D. Wait 4 hours between feedings so that your breasts will fill up.
Correct Answer: B
Rationale: Solid foods introduced before 4-6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every three months
- B. Take one tablet every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency. Replenishing every three months is not standard taking tablets every 15 minutes is incorrect (typically every 5 minutes up to 3 doses) and crushing is not appropriate.
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
- A. Providing the client with a favorite meal for dinner
- B. Asking if the client has allergies to shellfish
- C. Encouraging fluids the evening before the test
- D. Telling the client what to expect during the test
Correct Answer: B
Rationale: Intravenous pyelogram uses iodine-based contrast, which can cause allergic reactions, especially in clients with shellfish/iodine allergies. Identifying allergies is the highest priority for safety.
The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Hypothermia
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect. Hypothermia (B), nausea (C), and hyperactivity (D) are not associated with clopidogrel.
Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it:
- A. Is also called intrinsic factor
- B. Must be given in the abdomen
- C. Requires use of the Z-track method
- D. Should be given SC
Correct Answer: C
Rationale: The Z-track method prevents staining and irritation when administering iron dextran parenterally in a large muscle.