Atenolol: Nursing Drug Guide, Bradycardia & Hold Rules
Cardioselective beta blocker for hypertension and angina: the bedside priority is apical pulse and blood pressure before every dose—bradycardia, hypotension, and heart block can develop or worsen, and abrupt withdrawal in coronary artery disease can trigger severe angina, myocardial infarction, or ventricular arrhythmias.
Atenolol blocks beta-1 receptors, slowing heart rate and reducing contractility. The worst realistic failures are symptomatic bradycardia, hypotension, and second- or third-degree heart block—especially when combined with other nodal depressants or in patients with baseline conduction disease. In patients with coronary artery disease, abrupt discontinuation can precipitate severe angina, myocardial infarction, or ventricular arrhythmias. Nurses must measure apical pulse for a full minute and blood pressure before each dose, hold when parameters are out of range, and never stop or skip doses without prescriber-directed tapering.
📋 Contents
⚡ Quick facts
💡 Key takeaway
Count apical pulse for a full minute and check blood pressure before every atenolol dose. Hold when heart rate or blood pressure fall below prescriber or protocol limits, and coordinate a taper—never stop abruptly in angina or post-MI patients because rebound ischemia and arrhythmias can occur.
Most common brand names
Atenolol is available generically and as the long-established brand Tenormin (oral tablets). Combination product Tenoretic pairs atenolol with the thiazide diuretic chlorthalidone—verify whether the MAR lists single-entity atenolol or the combination to avoid duplicate beta-blocker or diuretic therapy.
Always confirm strength (25 mg, 50 mg, 100 mg) and that the patient is not receiving a second beta blocker from another prescriber or home medication list.
| Product | Components | Nursing verification |
|---|---|---|
| Tenormin | Atenolol alone | Match tablet strength to order; once-daily schedule |
| Tenoretic | Atenolol + chlorthalidone | Monitor potassium, sodium, orthostatic BP; avoid duplicate thiazide |
| Generic atenolol | Atenolol alone | Same hold rules; confirm manufacturer leaflet if enteral tube crushing needed |
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Why we give it — Indications
Atenolol is a cardioselective beta-1 adrenergic blocker used for long-term management of cardiovascular conditions where heart rate and myocardial oxygen demand must be controlled.
| Use | Detail |
|---|---|
| Hypertension | Lowering blood pressure reduces fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions per labeling. |
| Angina pectoris | Long-term management of angina associated with coronary artery disease. |
| Acute myocardial infarction | Early and late post-MI management in hemodynamically stable patients—follow institution-specific acute coronary syndrome protocols and current orders. |
| Not a primary vasodilator | Does not replace ACE inhibitors, ARBs, or calcium channel blockers ordered for other mechanisms—verify each antihypertensive on the MAR |
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How it works
Atenolol competitively blocks beta-1 adrenergic receptors, decreasing heart rate, contractility, and renin release from the kidney. Reduced myocardial oxygen demand helps control angina; lower cardiac output and peripheral effects contribute to antihypertensive action. At higher doses, cardioselectivity may lessen and beta-2 effects (bronchospasm, masking of hypoglycemia symptoms) can emerge—nurses should still assess lungs and glucose trends in at-risk patients.
| Physiologic effect | Clinical result | Nursing implication |
|---|---|---|
| ↓ Heart rate | Bradycardia, fatigue | Full-minute apical pulse before every dose |
| ↓ Contractility | Reduced cardiac output | Monitor BP and perfusion; caution in heart failure |
| ↓ Renin release | Lower BP | Expect gradual effect over 1–2 weeks—not immediate |
| ↓ AV nodal conduction | Heart block risk with nodal drugs | Hold for new block; review digoxin and CCB orders |
| Possible beta-2 blockade at high dose | Bronchospasm; masked hypoglycemia | Respiratory assessment; glucose monitoring in diabetes |
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Dosing overview
Dosing depends on indication, age, renal function, and response. Verify each order against current prescribing information and institutional protocols.
Post–myocardial infarction (hemodynamically stable patients): Follow institution-specific acute coronary syndrome pathways and the current prescriber order. Labeling describes early IV then oral maintenance regimens in selected post-MI populations—verify dose, route, and duration against the active order rather than assuming outpatient hypertension dosing.
| Scenario | Typical approach (labeling summary) | Nursing note |
|---|---|---|
| Hypertension — inadequate response at 50 mg | Increase to 100 mg once daily after 1–2 weeks | Recheck pulse and BP before dose escalation |
| Hypertension — doses >100 mg | Unlikely to add further BP lowering | Question duplicate antihypertensives before accepting higher orders |
| Angina — symptom persistence | May titrate up to 200 mg/day in divided doses | Assess angina frequency and exertional tolerance when titrating |
| CrCl 15–35 mL/min | Maximum 50 mg/day | Coordinate with pharmacy; document creatinine source and date |
| CrCl <15 mL/min | Maximum 25 mg/day | Monitor for accumulation-related bradycardia |
| Older adult initiation | May begin 25 mg/day | Fall precautions if dizziness; orthostatic BP checks |
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Missed dose: Not specified in the reviewed prescribing information for a single missed dose. Do not double doses. Contact prescriber or pharmacist if multiple doses are missed, especially in coronary artery disease, because abrupt interruption increases ischemic risk.
Onset, peak, duration, and half-life
| Parameter | Value | Nursing relevance |
|---|---|---|
| Onset (antihypertensive) | Not specified in the reviewed prescribing information as a single numeric value | Expect gradual blood pressure lowering over days; do not repeat or stack doses for same-day effect |
| Peak effect | Plasma levels peak 2–4 hours after oral dosing; steady-state antihypertensive effect in 1–2 weeks | Assess vitals on the routine schedule—not only immediately post-dose |
| Duration | Once-daily dosing supported by prolonged beta blockade | Missed doses matter for withdrawal risk in CAD; clarify taper if therapy interrupted |
| Half-life | Approximately 6–7 hours (plasma); elimination prolonged in renal impairment | Reduce dose when creatinine clearance falls; trend renal function with basic metabolic panel |
| Excretion | Renally eliminated without significant hepatic metabolism | Accumulation risk in acute kidney injury or advanced CKD—pharmacy review for dose caps |
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Before you give it — Safety check
Pretreatment checks
- Apical pulse for a full minute and blood pressure (supine and standing when orthostasis is a concern)
- 12-lead ECG or rhythm strip if history of heart block, syncope, or new palpitations
- Renal function (creatinine, estimated clearance) for dose limits
- Perform medication reconciliation for other beta blockers, calcium channel blockers, and nodal agents
Contraindications
- Sinus bradycardia, second- and third-degree AV block, cardiogenic shock, overt cardiac failure
- Known hypersensitivity to atenolol or formulation excipients
- Untreated pheochromocytoma (labeling requires alpha blockade before beta blockade)
Important interactions
| Drug / class | Effect | Nursing action |
|---|---|---|
| Digoxin | Additive slowing of AV conduction; bradycardia risk | Monitor pulse and rhythm closely; hold per parameters and notify prescriber for new bradyarrhythmia |
| Diltiazem / verapamil / other nodal drugs | Increased risk of bradycardia and heart block | Verify orders; trend vitals; escalate symptomatic hypotension or block |
| Insulin / oral hypoglycemics | May mask hypoglycemia symptoms (tachycardia, tremor) in type 2 diabetes | Teach glucose monitoring; do not rely on adrenergic warning signs alone |
| Sympathomimetics (e.g., epinephrine for anaphylaxis) | High beta-1 blockade may blunt bronchodilator response; unopposed alpha effects possible | Document beta-blocker use; follow anaphylaxis protocol and prescriber guidance |
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Asthma / reactive airways: Although atenolol is cardioselective, use caution in patients with asthma or bronchospastic disease; bronchospasm can occur, especially at higher doses or if selectivity is lost.
Perioperative and anesthesia considerations
Chronic beta-blocker therapy should not be stopped abruptly before noncardiac surgery per many guidelines, but the anesthesiologist and surgeon must know the patient takes atenolol. Unopposed alpha stimulation if epinephrine is required is a team concern—document beta-blocker use on preoperative checklists.
When atenolol is discontinued in patients with angina or after myocardial infarction, taper gradually per prescriber guidance and monitor for increased angina, arrhythmias, or blood pressure rebound. Nurses should clarify taper orders on discharge and teach patients not to run out of medication without a refill plan.
Administration
Route: Oral tablets once daily (morning or evening per order—consistency matters for blood pressure rhythm).
- May be taken with or without food per most formulations; swallow whole unless pharmacy approves splitting for specific products
- Do not crush extended-release products if dispensed—verify formulation
- Give at the same time each day when possible to maintain steady beta blockade
- If the patient cannot swallow, consult pharmacy for liquid alternatives or enteral tube compatibility—do not crush tablets without pharmacy approval
- Bedside identification: confirm Tenormin versus Tenoretic before administration; combination tablets include chlorthalidone
| Administration step | Action |
|---|---|
| Before dose | Apical pulse (60 seconds), blood pressure, compare to hold parameters, review MAR for duplicate beta blockers |
| During pass | Right patient, drug, dose, route, time; educate if pulse is borderline |
| After dose | Reassess orthostatic symptoms if hypotension risk; document hold or administration with vital signs |
| Discharge | Teach taper if discontinuing; provide refill plan; warn against stopping when BP improves |
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Expected therapeutic response
- Gradual reduction in resting heart rate and blood pressure toward prescriber targets
- Decreased frequency or severity of angina episodes when used for coronary artery disease
- Patient reports improved exercise tolerance without presyncope—if dizziness or fatigue worsen, reassess dose and hold parameters
Red flags — Stop and act
Bradycardia and conduction delay can progress to hemodynamic collapse. Abrupt withdrawal in ischemic heart disease is equally dangerous.
- Heart rate below prescriber hold limit, new second- or third-degree AV block, or pauses on monitor
- Symptomatic hypotension, syncope, or cold clammy extremities after dose
- Wheezing or bronchospasm in reactive airway disease—hold and escalate respiratory pathway
- Rest angina, crushing chest pain, or diaphoresis after missed doses or self-discontinuation—treat as acute coronary syndrome per protocol
- Signs of heart failure decompensation (crackles, weight gain, orthopnea) in patients with reduced ejection fraction
- Depression, confusion, or nightmares newly reported after dose increase—notify prescriber for mental status review
- Peripheral cyanosis or pain in fingers/toes suggesting severe beta-blockade—urgent perfusion assessment
Adverse effects
| Adverse effect | Frequency / notes | Nursing response |
|---|---|---|
| Bradycardia | Common; dose-related | Hold dose, notify prescriber, obtain rhythm strip; prepare for pacing pathway if symptomatic |
| Hypotension / dizziness | Common early in therapy or after dose increase | Assist with position changes; hold per parameters; monitor orthostatics |
| Fatigue, depression, sleep disturbance | Reported in beta-blocker class | Assess functional impact; notify prescriber if limits ADLs |
| Bronchospasm | Less common with cardioselective agent; still possible | Hold drug; bronchodilator therapy per prescriber; document allergy/intolerance |
| Masked hypoglycemia symptoms | Class effect in diabetes | Emphasize glucose checks; educate on sweating and confusion as alternate cues |
| Peripheral coldness / Raynaud symptoms | Class effect | Assess extremity perfusion; notify prescriber if painful or cyanotic |
| Sleep disturbance / vivid dreams | Central nervous system effect reported with beta blockers | Assess timing of dose; notify prescriber if distressing or persistent |
| Hyperkalemia (with Tenoretic) | Thiazide combination may affect electrolytes | Review BMP trends and symptoms of electrolyte imbalance |
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Overdose, toxicity, and antidote
Beta-blocker overdose causes bradycardia, hypotension, bronchospasm, and heart failure. There is no single specific antidote listed in the reviewed prescribing information.
Management per labeling
- Monitor and treat in intensive care: gastric lavage if early oral ingestion, activated charcoal, IV fluids
- Bradycardia: atropine; if inadequate, isoproterenol or transvenous pacing
- Hypotension: vasopressors (e.g., dopamine, dobutamine, norepinephrine) per protocol
- Heart failure: digitalize and diurese as appropriate; glucagon may be useful
- Bronchospasm: beta-2 stimulant aerosol or aminophylline IV
- Hemodialysis may remove atenolol because it is renally eliminated
| Overdose manifestation | Intervention (labeling summary) |
|---|---|
| Severe bradycardia | Atropine; isoproterenol or transvenous pacing if refractory |
| Hypotension | IV fluids; vasopressors (dopamine, dobutamine, norepinephrine) per protocol |
| Bronchospasm | Beta-2 aerosol or aminophylline IV |
| Heart failure | Digitalization and diuretics; glucagon may be useful |
| Drug removal | Hemodialysis may be effective because atenolol is renally excreted |
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Contact local poison control or medical toxicology services for overdose guidance per facility protocol and local emergency guidance.
Look-alike / sound-alike and error prevention
- Atenolol vs amlodipine / atorvastatin—verify drug name on MAR and patient teach-back
- Tenormin vs Tenoretic—combination contains chlorthalidone; duplicate diuretic risk if another thiazide is ordered
- Multiple beta blockers—atenolol plus other beta blockers from different providers (duplicate therapy risk)
- Atenolol vs metoprolol name confusion—both end in “-olol”; read full generic name on label and MAR
- Dose strength—25 mg vs 50 mg vs 100 mg tablets; renal caps differ from standard hypertension dosing
- Abrupt stop—patient may confuse hold for stop; document taper orders clearly
High-risk populations
| Population | Considerations |
|---|---|
| Coronary artery disease / post-MI | Never discontinue abruptly; taper gradually with monitoring per prescriber guidance; rebound angina and MI reported |
| Older adults | Start 25 mg daily; higher risk of bradycardia and hypotension; fall risk with dizziness |
| Renal impairment | Dose caps: CrCl 15–35 mL/min max 50 mg/day; CrCl <15 max 25 mg/day |
| Diabetes mellitus | Masks hypoglycemia tachycardia; monitor glucose closely |
| Reactive airway disease | Use caution; bronchospasm possible despite cardioselectivity |
| Pregnancy / lactation | Consult LactMed and MotherToBaby references; fetal growth restriction reported with beta blockers—balance maternal benefit vs risk with prescriber |
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Monitoring and documentation
Monitor
- Apical pulse (full minute), blood pressure, and rhythm before each dose and when symptoms change
- Orthostatic vital signs after dose increases or in fall-risk patients
- Renal function and electrolytes when diuretics are co-prescribed (Tenoretic or separate thiazide)
- Blood glucose trends in diabetes; angina frequency and exertional symptoms in CAD
Document
- Heart rate, blood pressure, and whether dose was held with prescriber notification
- Taper plan when discontinuing; patient education on not stopping abruptly
- Any bronchospasm, syncope, or angina after missed doses
| Parameter | Typical nursing frequency | Action threshold (verify local protocol) |
|---|---|---|
| Apical pulse | Before each dose; when symptoms change | Hold and notify if below prescriber minimum (often <60/min in adults) |
| Blood pressure | Before each dose; orthostatics after dose changes | Hold for symptomatic hypotension or SBP below protocol limit |
| Rhythm | When pulse irregular or patient reports palpitations | Obtain ECG or rhythm strip; hold for new AV block |
| Creatinine / eGFR | Per admission and when renal status changes | Pharmacy review when eGFR declines toward dose-cap ranges |
| Blood glucose | Per diabetes plan when on insulin or sulfonylureas | Teach alternate hypoglycemia cues when beta blocker masks tachycardia |
| Angina symptoms | Each shift in CAD; after missed doses | Escalate rest angina or increasing frequency—possible withdrawal or undertreatment |
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Patient teaching
- Take at the same time daily; do not double doses if one is missed—call the clinic for guidance
- Never stop suddenly if you have heart disease or angina; prescriber will taper the dose
- Check pulse before taking if instructed; report heart rate below your prescriber limit, fainting, or new wheezing
- Rise slowly from sitting or lying down to reduce dizziness
- If you have diabetes, monitor blood glucose as directed—this medicine can hide shaking and fast heartbeat during low sugar
- Inform all clinicians and dentists that you take a beta blocker before procedures requiring epinephrine or certain anesthetics
| Teach-back topic | Patient should be able to say |
|---|---|
| Pulse check | How to count pulse for one minute and when to call if too slow |
| Missed doses | Do not double; call clinic if several doses missed |
| Stopping therapy | Prescriber must taper—never stop suddenly if heart disease |
| Diabetes | Sweating or confusion may still occur; check glucose as directed |
| When to seek care | Fainting, severe dizziness, chest pain, new wheezing |
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The Hold Rule
Do not give and contact the prescriber/pharmacist when:
- Apical pulse below prescriber or protocol minimum (commonly <60 beats/min in adults—verify institutional parameters)
- Systolic blood pressure below hold threshold or symptomatic hypotension
- New second- or third-degree AV block, sick sinus syndrome, or symptomatic bradycardia on monitor
- Active bronchospasm or severe reactive airway exacerbation
- Patient self-discontinued or multiple doses missed in CAD—do not restart full dose without prescriber/pharmacy plan
- Order exceeds renal maximum for documented creatinine clearance
Hold parameters may vary by institutional protocol. Follow prescriber orders, pharmacy guidance, and facility policy.
| Common institutional hold example | Nursing action |
|---|---|
| Apical pulse <60/min | Hold dose; notify prescriber; recheck in 30–60 minutes per protocol |
| SBP <100 mmHg or symptomatic low BP | Hold; orthostatic assessment; notify prescriber |
| New heart block or irregular pulse | Hold; obtain rhythm strip; urgent notification |
| Active wheeze / bronchospasm | Hold; treat respiratory symptoms; notify prescriber |
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Practical bedside notes
| Topic | Bedside guidance |
|---|---|
| Pulse check | Apical count full 60 seconds—radial pulse may be irregular or weak with block |
| Timing | Once daily; align with home routine on discharge teaching |
| Perioperative | Continue or hold per anesthesia/prescriber plan—abrupt withdrawal risky in CAD |
| Tenoretic | Includes chlorthalidone—monitor potassium and orthostatics |
| Commonly missed | Second beta blocker on home list; patient stops drug when BP looks normal |
| Ask pharmacy when | Renal dose adjustment, drug interaction with nodal agents, or taper schedule after MI/angina |
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Clinical practice integration and workflow
Atenolol is a maintenance cardiovascular drug whose safety hinges on vital signs before administration and disciplined tapering at discontinuation—not on complex infusion technique.
1. Check-before-you-give protocol
- Right patient, drug, dose, route, time—and right apical pulse and blood pressure
- Compare heart rate to hold parameters on the MAR and nursing protocol
- Screen for duplicate beta-blocker therapy on MAR and home med list
- Verify renal dose cap when creatinine clearance is reduced
2. High-alert and safety badge
Not an ISMP high-alert medication, but bradycardia and withdrawal ischemia require the same vital-sign disciplineTreat pre-dose pulse and blood pressure checks as non-negotiable even when the drug is not on your facility high-alert list.
3. Clinical workflow: hold and question rules
- If pulse or blood pressure is below threshold, hold and notify before giving—do not administer and document later
- If the patient skipped several doses, clarify restart vs taper with pharmacy—especially post-MI or angina
- Before surgery, confirm perioperative beta-blocker plan with anesthesia and cardiology
4. Critical teach-back questions
- “What should you do if your pulse is too slow before your pill?” (Hold and call prescriber/clinic per instructions—do not take the dose.)
- “Can you stop this medicine when your blood pressure looks good?” (No—prescriber must taper; sudden stop can cause chest pain or heart attack in heart disease.)
5. Care coordination
Pharmacist: Renal dosing, interaction review with digoxin and calcium channel blockers, taper schedules
Prescriber / cardiology: Symptomatic bradycardia, heart block, failed angina control, or perioperative beta-blocker decisions
🧠 Quick mental checklist
- Apical pulse for full minute and BP before this dose?
- Below hold heart rate or blood pressure?
- Any nodal drugs (digoxin, diltiazem) increasing block risk?
- Renal function supports current dose cap?
- If stopping therapy, is there a taper—not abrupt discontinuation?
Atenolol NCLEX practice questions
This NCLEX-style clinical judgment practice set for atenolol uses a tabbed inpatient case (MAR, labs, vitals, nursing notes), then priority action, cue recognition, trend interpretation, matrix urgency sorting, withdrawal judgment, and overdose management cloze—recognise cues → analyse → prioritise → act → evaluate outcomes (bradycardia vs safe parameters vs ischemic rebound).
Select a tab to view MAR, labs, vitals, and nursing note details for this case.
- Atenolol 50 mg PO daily — due 0800; held yesterday for HR 52
- Digoxin 0.125 mg PO daily — given 0700
- Lisinopril 10 mg PO daily — given 0700
- Metformin 500 mg PO BID with meals
- Creatinine 1.4 mg/dL (baseline 1.1); eGFR estimated 38 mL/min
- Potassium 4.2 mEq/L; glucose 142 mg/dL fasting
- Prior BMP stable; pharmacy note: renal dose review for atenolol
- Apical pulse 58/min regular; BP 118/72 supine; BP 104/68 standing
- SpO2 97% on room air; denies chest pain; mild lightheadedness on standing
- Hold parameters on chart: give if apical pulse ≥60 and SBP ≥100
- History: hypertension, type 2 diabetes, prior angina; no pacemaker
- 0700: Patient reports skipped two home doses while traveling—restarted hospital atenolol yesterday, then held for bradycardia
- 0730: Asks whether to take morning pill because BP “looks good”
Answer key & rationale
Frequently asked questions
Common nursing questions about atenolol focus on pre-dose pulse checks, hold parameters, safe discontinuation, expected adverse effects, and overdose management when no single antidote exists.
What should I check before giving atenolol?
Count apical pulse for a full minute and obtain blood pressure (and orthostatic measurements when indicated). Review hold parameters on the MAR, check for nodal drugs such as digoxin or calcium channel blockers, and confirm renal function supports the ordered dose. Document findings before administration.
When should a nurse hold atenolol?
Hold when apical pulse or blood pressure falls below prescriber or protocol limits, when new second- or third-degree AV block or symptomatic bradycardia is present, during active bronchospasm, or when the ordered dose exceeds renal maximums. Also hold and clarify if the patient missed multiple doses in coronary artery disease—do not restart full dose without prescriber/pharmacy guidance.
Can atenolol be stopped suddenly?
No. Prescribing information warns that abrupt discontinuation in patients with coronary artery disease can precipitate severe angina, myocardial infarction, or ventricular arrhythmias. When discontinuation is planned, taper gradually with monitoring per prescriber guidance—do not stop suddenly.
What adverse effects matter most with atenolol?
Bradycardia, hypotension, fatigue, dizziness, heart block, bronchospasm in reactive airways, and masked hypoglycemia symptoms in diabetes are the highest-impact effects for bedside nurses.
Is there an antidote for atenolol overdose?
There is no single specific antidote in the reviewed prescribing information. Management is supportive: atropine, isoproterenol or pacing for bradycardia, vasopressors for hypotension, glucagon for heart failure, beta-2 stimulants for bronchospasm, and hemodialysis because the drug is renally eliminated. Contact local poison control or medical toxicology per facility protocol.
References
-
U.S. National Library of Medicine. TENORMIN (atenolol) tablet — Full prescribing information. DailyMed.https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=15c0c2df-f195-45f9-a1e4-1ed2a43c2216
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Drugs and Lactation Database (LactMed). Atenolol. Bethesda (MD): National Institute of Child Health and Human Development.https://www.ncbi.nlm.nih.gov/books/NBK501142/
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MotherToBaby. Atenolol. Organization of Teratology Information Specialists.https://www.ncbi.nlm.nih.gov/books/NBK582585/
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American Heart Association. Types of blood pressure medications — Beta blockers.https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications
Review and transparency
This medication guide is written and reviewed using NurseOnShift editorial and clinical review standards.
Educational use only. This content does not replace clinical judgment, prescriber orders, pharmacist guidance, product labeling, or institutional protocols.
Last content review: May 25, 2026.