Author Question: Which assessment finding indicates uterine rupture? a. Fetal tachycardia occurs. b. The client ... (Read 79 times)

Mr3Hunna · **on:** Jun 28, 2018

Which assessment finding indicates uterine rupture?

a. Fetal tachycardia occurs.
b. The client becomes dyspneic.
c. Labor progresses unusually quickly.
d. Contractions abruptly stop during labor.

Question 2

Which is (are) the priority nursing assessment(s) for the client having tocolytic therapy with terbutaline (Brethine)?

a. Intake and output
b. Maternal blood glucose level
c. Internal temperature and odor of amniotic fluid
d. Fetal heart rate, maternal pulse, and blood pressure

aadams68 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
A large rupture of the uterus will disrupt its ability to contract. Fetal tachycardia is a sign of hypoxia. With a large rupture, the nurse should be alert for the earlier signs. Dyspnea is not an early sign of a rupture. Contractions will stop with a rupture.

Answer to Question 2

ANS: D
All assessments are important, but those most relevant to the medication include the fetal heart rate and maternal pulse, which tend to increase, and the maternal blood pressure, which tends to exhibit a wide pulse pressure. Intake and output and glucose are not important assessments to monitor for side effects of terbutaline. Internal temperature and odor of amniotic fluid are important if the membranes have ruptured, but these are not relevant to the medication.