A nurse is assessing a client with pre-eclampsia who is receiving oxytocin for labor induction.
Which finding would alert the nurse to suspect that the client is developing HELLP syndrome?
Epigastric pain or right upper quadrant pain
Blurred vision or flashes of light
Decreased urinary output or oliguria
Hyperreflexia or clonus
The Correct Answer is A
This is because HELLP syndrome is a complication of pregnancy that affects the liver and blood clotting. It can cause liver damage, bleeding problems, and high blood pressure. Epigastric pain or right upper quadrant pain is a sign of liver injury or rupture.
Choice B is wrong because blurred vision or flashes of light are symptoms of preeclampsia, not HELLP syndrome.
Preeclampsia is a condition that causes high blood pressure and protein in the urine during pregnancy. It can lead to HELLP syndrome, but not all women with preeclampsia develop HELLP syndrome.
Choice C is wrong because decreased urinary output or oliguria are also symptoms of preeclampsia, not HELLP syndrome.
Oliguria means producing less than 400 mL of urine in 24 hours. It can indicate kidney damage or failure due to high blood pressure or proteinuria.
Choice D is wrong because hyperreflexia or clonus are also symptoms of preeclampsia, not HELLP syndrome.
Hyperreflexia means having exaggerated reflexes, while clonus means having involuntary muscle spasms.
They can indicate nervous system involvement or seizures due to high
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This indicates a therapeutic level of magnesium sulfate for a client with severe pre-eclampsia who is receiving magnesium sulfate.According to some sources, the effective therapeutic serum magnesium level is 1.8–3.0 mmol/L, which corresponds to 4.2–7 mg/dL or 3.5–7 mEq/L.
Choice B is wrong because serum calcium level of 8.5 mg/dL is within the normal range and does not indicate the effect of magnesium sulfate.
Choice C is wrong because serum creatinine level of 1.2 mg/dL is within the normal range and does not indicate the effect of magnesium sulfate.
Choice D is wrong because serum potassium level of 3.5 mEq/L is at the lower end of the normal range and does not indicate the effect of magnesium sulfate.
Correct Answer is C
Explanation
Deep tendon reflexes.
The nurse should monitor the client’s deep tendon reflexes to assess for signs of magnesium toxicity, which can cause respiratory depression, cardiac arrest, and coma.Magnesium sulfate is given to prevent seizures in clients with severe preeclampsia, but it can also have adverse effects on the neuromuscular system.
Choice A is wrong because blood pressure is not the most important assessment for a client receiving magnesium sulfate.
Blood pressure is a manifestation of preeclampsia, but it does not indicate magnesium toxicity.
Choice B is wrong because urine output is not the most important assessment for a client receiving magnesium sulfate.
Urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium, but it does not reflect the level of magnesium in the blood.
Choice D is wrong because fetal heart rate is not the most important assessment for a client receiving magnesium sulfate.
Fetal heart rate is important to monitor for signs of fetal distress, but it does not indicate maternal magnesium toxicity.
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