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 B
Explanation
Choice A rationale
Informing the client to expect dark-colored stools is inaccurate for methotrexate administration. Dark stools typically indicate gastrointestinal bleeding, not a side effect of methotrexate.
Choice B rationale
Wearing two pairs of gloves is necessary when handling methotrexate as it is a cytotoxic drug. This protects healthcare workers from accidental exposure to the medication, which can be harmful.
Choice C rationale
Methotrexate is typically administered intramuscularly or orally, not subcutaneously. Administering it subcutaneously is incorrect and would not be effective for treating an ectopic pregnancy.
Choice D rationale
While it is essential to counsel the client on safe intercourse practices, instructing to use a condom for only 7 days post-administration is not specific or relevant to the methotrexate therapy for ectopic pregnancy.
Correct Answer is B
Explanation
Choice A rationale
A positive pregnancy test is a probable sign of pregnancy as it indicates the presence of hCG, a hormone produced during pregnancy. However, it is not a presumptive sign, as other
conditions can also result in elevated hCG levels.
Choice B rationale
Amenorrhea, or the absence of menstrual periods, is a presumptive sign of pregnancy. It is one of the earliest indications that a woman may be pregnant, though it can also be
caused by other factors such as stress or hormonal imbalances.
Choice C rationale
Fetal heart sounds detected by Doppler ultrasound are a positive sign of pregnancy, confirming the presence of a fetus. This is not a presumptive sign as it is direct evidence of
pregnancy.
Choice D rationale
Chadwick's sign, a bluish discoloration of the cervix, vagina, and labia due to increased blood flow, is considered a probable sign of pregnancy. It is not a presumptive sign but rather
a physical change that occurs during pregnancy. .