A nurse in an obstetrics clinic is caring for a client.

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Exhibit 1

Nurses' Notes

Initial visit, 1340:

29-year-old gravida 2, para 0 client presents with report of a positive home pregnancy test from 2 weeks ago. Last menstrual period was 7 weeks ago. Urine human chorionic gonadotropin (hCG) positive. Client reports vomiting several times a day over the last 2 weeks and states, "I'm a vegetarian and I don't usually eat a lot of protein, but it's still hard to keep anything down." Decreased skin turgor noted, oral mucous membranes moist. Weight 79.4 kg (175 lb).

Exhibit 2

Vital Signs

Initial visit, 1330:

• Heart rate 110/min
• Respiratory rate 18/min
• Blood pressure 104/66 mm Hg
• Temperature 36.6° C (97.9° F)
• Oxygen saturation 99% on room air
• Continuation of above exhibit

Exhibit 3

The nurse is reviewing the client's assessment findings and laboratory results.

Laboratory Results

Initial visit, 1600:

• WBC count 7,500/mm3 (5,000 to 10,000/mm3)
• Hgb 10.2 g/dL (11 to 16 g/dL)
• Hct 45% (33% to 47%)
• Platelets 360,000/mm3 (150,000 to 400,000/mm3)
• Sodium 136 mEq/L (136 to 145 mEq/L)
• Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
• BUN 28 mg/dL (10 to 20 mg/dL)

Urinalysis:

• Appearance clear (clear)
• Color dark amber (pale yellow amber)
• pH 7.9 (4.6 to 8)
• Protein 4 mg/dL (0 to 8 mg/dL)
• Specific gravity 1.045 (1.005 to 1.03)
• Leukocyte esterase negative (negative)
• Nitrites none (none)

A. Bilirubin 1 mg/dL (0.1 to 1 mg/dL):

Bilirubin levels can be elevated in conditions involving liver dysfunction or hemolysis, such as HELLP syndrome. However, a bilirubin level of 1 mg/dL falls within the normal range (0.1 to 1 mg/dL). While bilirubin levels may be elevated in some cases of HELLP syndrome, this particular value is not indicative of HELLP syndrome.

B. Uric acid 6.8 mg/dL (2 to 6.6 mg/dL):

Elevated uric acid levels are commonly seen in preeclampsia, but they are not specific to HELLP syndrome. Uric acid levels can rise due to decreased renal function and increased cell breakdown. However, while a level of 6.8 mg/dL is slightly elevated compared to the normal range (2 to 6.6 mg/dL), it alone does not confirm the presence of HELLP syndrome.

C. Fibrinogen 500 mg/dL (200 to 400 mg/dL):

Fibrinogen levels are typically increased in pregnancy, but they can be decreased in conditions associated with consumption coagulopathy, such as disseminated intravascular coagulation (DIC). However, elevated fibrinogen levels are not typically associated with HELLP syndrome. A level of 500 mg/dL is above the normal range (200 to 400 mg/dL), but this finding alone does not indicate HELLP syndrome.

D. Aspartate aminotransferase (AST) 80 units/L (4 to 20 units/L):

Aspartate aminotransferase (AST) is a liver enzyme that can be elevated in liver injury or dysfunction, which can occur in HELLP syndrome. An AST level of 80 units/L is significantly elevated compared to the normal range (4 to 20 units/L), suggesting liver dysfunction. Elevated liver enzymes are a characteristic feature of HELLP syndrome, making this finding the most indicative of HELLP syndrome among the options provided.

A. Human papillomavirus (HPV) vaccine:
The HPV vaccine is not recommended during pregnancy because there is limited safety data regarding its use in pregnant women. It is typically administered to individuals before they become sexually active to prevent HPV infections, which can lead to cervical cancer and other HPV-related diseases. Since the client is currently pregnant, administering the HPV vaccine would not be appropriate due to the lack of safety data during pregnancy.

B. Rubella vaccine:
The rubella vaccine is a live attenuated vaccine, and its administration during pregnancy is contraindicated due to the risk of congenital rubella syndrome (CRS) if the vaccine were to cause rubella infection in the pregnant woman. Rubella vaccination should be provided to non-pregnant individuals, particularly women of childbearing age, to prevent CRS. Administering the rubella vaccine to a pregnant woman at 28 weeks of gestation would pose a risk to both the mother and the developing fetus.

C. Varicella vaccine:
Similar to the rubella vaccine, the varicella (chickenpox) vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of varicella infection in the pregnant woman, which can lead to severe complications for both the mother and the fetus. Varicella vaccination is recommended for individuals who have not had chickenpox or received the vaccine previously but should not be administered to pregnant women.

D. Tetanus vaccine:
Tetanus vaccination during pregnancy is recommended to prevent maternal and neonatal tetanus. Tetanus toxoid is considered safe during pregnancy and is routinely administered as part of the tetanus-diphtheria-pertussis (Tdap) vaccine. The tetanus vaccine helps protect against tetanus, a potentially fatal bacterial infection. Administering the tetanus vaccine during pregnancy is important for the health and safety of both the mother and the developing fetus.