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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.

A.

"I will inject this medication under your skin."

B.

"You may experience a headache after receiving this medication."

C.

"It is common for this medication to make you feel jittery."

D.

"This medication should decrease your contractions."

Question Solution

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 C

Explanation

Choice A rationale

Feeding from only one breast can lead to engorgement and a decrease in milk supply in the affected breast. It is important to continue breastfeeding from both breasts, even if one is infected.

Choice B rationale

Discarding milk is not necessary and can lead to a decrease in milk supply. The infection does not harm the baby, and breastfeeding helps to drain the breast and clear the infection.

Choice C rationale

Moist heat can help to increase blood flow and promote healing in the affected breast. Applying warm compresses or taking warm showers can help to reduce pain and inflammation associated with mastitis.

Choice D rationale

While staying hydrated is important for overall health, there is no specific requirement to drink at least 1500 milliliters of fluid per day for mastitis. Adequate fluid intake should be maintained, but there is no direct correlation with resolving the infection.

Correct Answer is A

Explanation

Choice A rationale

Terbutaline can cause tachycardia. A heart rate of 132/min is significantly higher than normal and could indicate severe cardiovascular effects.

Choice B rationale

While headaches can occur with terbutaline, they are generally not life-threatening and don't require immediate intervention compared to tachycardia.

Choice C rationale

Nasal congestion is a minor side effect and not a priority compared to a significantly elevated heart rate.

Choice D rationale

Tremors are common with terbutaline use, but they are usually not as concerning as a significantly elevated heart rate

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