A nurse is caring for a 28-year-old female client who is gravida 1 para 0 at 32 weeks of gestation in the prenatal unit.
Exhibit 1: History and PhysicalThe client is a 28-year-old female, gravida 1 para 0 at 32 weeks of gestation. She reports cramping and low back pain that started about 3 hours ago, with pain rated 2 on a scale of 0 to 10. She believes the contractions feel stronger than Braxton Hicks and expresses concern that it's too early for labor pains. The client mentions a small amount of urinary leakage earlier in the day, but no vaginal bleeding. She decided to come in for evaluation upon her doctor's advice.Exhibit 2: Nurses' NotesAt 0900, the client stated that she began experiencing cramping and low back pain approximately 3 hours ago, rating the pain as 2 out of 10. She described the contractions as stronger than Braxton Hicks but believed they were not labor pains. She also mentioned experiencing a small amount of urinary leakage earlier in the day, with no vaginal bleeding reported. The external fetal monitor indicated contractions every 5 minutes, lasting 30 seconds each, with moderate intensity upon palpation. Fetal heart rate was recorded at 140 beats per minute. A vaginal exam revealed a closed cervix that was 80% effaced, with clear mucus discharge observed on the exam glove.Exhibit 3: Vital SignsBlood Pressure: 120/80 mmHgHeart Rate: 80 bpmRespiratory Rate: 18 breaths/minTemperature: 98.6°F (37°C)Oxygen Saturation: 98%Exhibit 4: Physical Examination ResultsUpon physical examination, the client appeared anxious but was otherwise in stable condition. Her abdomen was soft and non-tender, with no signs of rigidity. Fetal movements were noted to be active. The client had no edema in her extremities, and her reflexes were normal. Auscultation of the lungs revealed clear breath sounds bilaterally. Cardiovascular examination showed a regular heart rhythm without any murmurs. The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include? Select all that apply.
"I will inject this medication under your skin."
"You may experience a headache after receiving this medication."
"It is common for this medication to make you feel jittery."
"This medication should decrease your contractions."
Correct Answer : B,C,D,E,F
A. "I will inject this medication under your skin.": Tocolytic medications are typically administered orally, intravenously, or intramuscularly, not subcutaneously.
B. "You may experience a headache after receiving this medication."
Some tocolytic medications can cause headaches as a side effect.
C. "It is common for this medication to make you feel jittery."
Tocolytic medications, such as terbutaline, can cause nervousness or jitteriness.
D. "This medication should decrease your contractions."
The primary purpose of tocolytic medication is to decrease uterine contractions and delay preterm labor.
E. "I'll check your reflexes frequently while you are receiving this medication."
Some tocolytic medications, like magnesium sulfate, require monitoring of deep tendon reflexes to assess for potential toxicity.
F. "This medication can make your heart beat faster."
Tocolytic medications, such as terbutaline, can increase heart rate.
G. "This medication can increase your blood pressure.":
Some tocolytic medications, like magnesium sulfate, can actually lower blood pressure rather than increase it.
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Correct Answer is D
Explanation
Choice A rationale
Transient circumoral cyanosis is common in newborns, especially when crying or feeding, and usually resolves on its own without intervention.
Choice B rationale
Transient strabismus, or the temporary crossing of the eyes, is normal in newborns due to underdeveloped eye muscles and usually resolves as the infant grows.
Choice C rationale
Caput succedaneum is the swelling of the scalp caused by pressure during delivery. It is usually benign and resolves within a few days without treatment.
Choice D rationale
Generalized petechiae, or small red or purple spots on the skin, can indicate a serious underlying condition such as a clotting disorder or infection and requires immediate medical evaluation.
Correct Answer is A
Explanation
Choice A rationale
Rear-facing car seats are safer for infants and toddlers because they provide better support for their head, neck, and spine in the event of a collision. The American Academy of Pediatrics recommends keeping children in rear-facing seats until they are at least 2 years old or until they reach the highest weight or height allowed by the manufacturer.
Choice B rationale
A four-point harness is not sufficient for securing a baby in a car seat. A five-point harness, which includes two shoulder straps, two hip straps, and one crotch strap, provides more secure and effective restraint for infants.
Choice C rationale
The shoulder harness should be positioned in the slots at or below the baby's shoulders, not above, to ensure proper fit and restraint. Placing the harness above the shoulders can result in improper restraint and increased risk of injury in an accident.
Choice D rationale
The correct angle for a rear-facing car seat is typically 45 degrees, not 30 degrees. A 45-degree angle ensures the baby's airway remains open, preventing the head from falling forward and potentially causing breathing difficulties.