A client is receiving terbutaline (Brethine) IV for preterm labor. Which of the following maternal findings would warrant stopping the infusion?

Correct Answer: A

Rationale: In the case of a client receiving terbutaline (Brethine) IV for preterm labor, the correct answer warranting stopping the infusion is option A) Cardiac arrhythmias. Terbutaline is a beta-2 adrenergic agonist that can potentially lead to adverse cardiac effects such as tachycardia, palpitations, and arrhythmias. These effects can be exacerbated in the IV route due to the rapid onset of action. Option B) Respiratory rate of 24 rpm is within normal limits and not a direct contraindication for stopping the infusion. Option C) Blood pressure of 90/60 is low but not an immediate concern unless accompanied by symptoms of shock. Option D) Hypocalcemia is not a common adverse effect of terbutaline and would not be a primary reason to stop the infusion. Educationally, this question highlights the importance of monitoring maternal responses to medications during pregnancy, especially those used to manage preterm labor. Understanding the potential side effects and contraindications of medications like terbutaline is crucial for providing safe and effective care to pregnant clients. Vigilant assessment and prompt intervention based on assessment findings are essential in managing maternal and fetal well-being during pregnancy.

Correct Answer: B

Rationale: In the postpartum period, it is crucial for nurses to assess and monitor various aspects of a mother's health, including the risk for fluid volume deficit. The appropriate goal for a postpartum client with a nursing diagnosis of potential for fluid volume deficit is to maintain a normal lochial flow (Option B). Explanation of why Option B is correct: - Lochia is the postpartum vaginal discharge containing blood, mucus, and uterine tissue. Monitoring and ensuring a normal lochial flow is essential in assessing postpartum hemorrhage and fluid status. Any deviation from normal lochial flow could indicate a potential issue with fluid volume balance. Explanation of why other options are incorrect: - Option A (Minimal perineal pain): While important for the mother's comfort, perineal pain is not directly related to fluid volume deficit. - Option C (Normal temperature): Temperature regulation is important but not specifically related to fluid volume deficit. - Option D (Weight reduction): Weight reduction is not a priority in the immediate postpartum period and is not directly related to fluid volume status. Educational context: Understanding nursing diagnoses, setting appropriate goals, and prioritizing interventions based on the client's needs are critical skills for nurses in maternal health. Monitoring and managing fluid volume balance in the postpartum period are vital for preventing complications and promoting recovery. By selecting the correct goal related to fluid volume balance, nurses can provide effective care and support to postpartum clients.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) When gastric aspirate is removed from the tube. This is because the presence of gastric aspirate confirms that the tube is in the stomach, which is the intended location for an orogastric gavage tube. Option B) When the baby suckles on the tubing is incorrect because a baby suckling on the tubing does not provide a reliable indication of proper tube placement. It can be a dangerous assumption to rely on the baby's action to determine tube location. Option C) When respirations are unlabored during tube insertion is incorrect as it does not directly correlate with tube placement. Unlabored respirations indicate the baby's overall respiratory status, not tube location. Option D) When the tubing can be inserted no farther is incorrect because the length of insertion does not guarantee correct placement. It's important to verify the tube location through appropriate means like aspirating gastric contents. In the educational context, it is crucial for nurses to understand the importance of verifying tube placement using evidence-based methods to ensure the safety and well-being of the preterm baby. Proper tube placement is essential to prevent complications such as aspiration and ensure effective delivery of nutrition or medication. Nurses must follow established protocols and guidelines to confirm tube placement accurately.

Correct Answer: A

Rationale: The correct answer is A) Nothing, because this is an acceptable weight loss. In the first few days after birth, it is common for newborns to lose up to 10% of their birth weight. This weight loss is mainly due to the loss of excess fluid and meconium. In the case of this 4-day-old neonate who has lost 286 grams (which is within the expected range), there is no cause for alarm. Option B) Advise the mother to stop breastfeeding and give formula is incorrect because breastfeeding should be continued as it provides numerous health benefits to both the baby and the mother. Formula feeding is not necessary in this situation. Option C) Notify the neonatologist of the excessive weight loss is incorrect because the weight loss described is within the normal range for a newborn. There is no need to escalate the situation to the neonatologist. Option D) Give the baby dextrose water between breast feedings is incorrect because there is no indication to provide dextrose water to a newborn who is breastfeeding and experiencing normal weight loss. Introducing unnecessary supplements can disrupt breastfeeding and may not be beneficial. In an educational context, understanding the normal weight changes in newborns is crucial for healthcare providers working with infants and new mothers. Educating nurses and caregivers about expected weight loss in neonates can help prevent unnecessary interventions and promote successful breastfeeding practices.

Correct Answer: C

Rationale: In the immediate postpartum period, the priority nursing care goal for a client who had a vaginal delivery 2 hours earlier is to monitor and ensure a moderate lochial flow (Option C). Lochia is the vaginal discharge after childbirth, and assessing its amount, color, and odor is crucial in detecting signs of excessive bleeding or infection, which are common postpartum complications. Monitoring for a moderate flow indicates that the uterus is contracting well and decreasing the risk of hemorrhage, a critical concern in the early postpartum period. Option A, breastfeeding every 2 hours, is important for bonding and infant nutrition but is not the highest priority within the first few hours after delivery. Option B, consuming a nutritious diet, is important for recovery but is not as immediate a concern as monitoring for postpartum complications. Option D, ambulation, is beneficial for preventing complications such as deep vein thrombosis but is not as critical as ensuring proper uterine contraction and assessing for excessive bleeding. Educationally, this question highlights the importance of prioritizing nursing care goals based on the immediate needs of postpartum clients to ensure optimal outcomes and prevent complications in the early postpartum period. Understanding the significance of monitoring lochial flow can help students and healthcare providers provide safe and effective care to postpartum clients.