Difficulty: Medium
Average Score: 74%
Full-length
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to
Correct answer
A
Rationale
Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (B) is not within nursing scope, administering (C) ignores the risk, and waiting (D) delays intervention.