Nursing implications related to tocolytic therapy include:
a. Immediately reporting a maternal heart rate of 100 beats/minute or greater
b. Recognizing a blood pressure of 80/40 mm Hg as an expected side effect
c. Comparing intake and output to detect maternal fluid retention
d. Discontinuing the infusion if the patient reports muscle weakness
ANS: C
Although tocolytics have many adverse effects, the greatest threat to the mother is fluid retention and pulmonary edema. Vital signs that should be reported immediately are pulse equal to or greater than 120 beats/minute, systolic blood pressure less than 90 mm Hg, and diastolic blood pressure less than 40 mm Hg.
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