A nurse is assessing four clients in a prenatal clinic.
Which of the following clients should the nurse recommend that the provider see first?

Choice A rationale

Herpes simplex virus 2 (HSV-2) can be harmful to a developing fetus and newborn. While primary infection during the first trimester can rarely lead to congenital anomalies, the most significant risk is neonatal herpes, which occurs when the newborn is exposed to the virus during passage through the birth canal if active lesions are present. Neonatal herpes can cause severe, life-threatening complications.

Choice B rationale

Transmission of HSV-2 to the newborn is significantly higher if active genital lesions are present at the time of vaginal birth. The virus can be shed from these lesions and infect the infant as they pass through the birth canal. Therefore, a Cesarean section is typically recommended if active lesions are present at the onset of labor.

Choice C rationale

Wearing tight-fitting undergarments can increase moisture and friction, potentially irritating existing lesions and hindering healing. Loose-fitting cotton undergarments are generally recommended to allow air circulation and reduce irritation, promoting a more favorable environment for lesion resolution and comfort.

Choice D rationale

Antiviral medications, such as acyclovir, valacyclovir, or famciclovir, can help manage genital herpes by reducing the frequency, duration, and severity of outbreaks. They work by inhibiting viral replication. However, these medications do not cure the condition; HSV-2 remains a lifelong viral infection.

The client is at risk for developing HELLP syndrome as evidenced by Liver enzymes.

Rationale for correct answers:
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe form of preeclampsia often presenting in the third trimester. This client has thrombocytopenia (platelets 100,000/mm³; normal 150,000–400,000/mm³), elevated blood urea nitrogen (25 mg/dL; normal 10–20 mg/dL), borderline elevated creatinine (1.1 mg/dL; normal 0.5–1.0 mg/dL), and elevated uric acid (9.8 mg/dL; normal 2.7–7.3 mg/dL), which suggests possible renal impairment and oxidative stress typical in HELLP. Mild epigastric discomfort also aligns with liver involvement. Although liver enzymes are not listed in the labs here, the question implies liver enzyme elevation as a hallmark finding to confirm HELLP, which is essential to monitor. Hemolysis would typically manifest as anemia, but hemoglobin and hematocrit are near normal. Prompt recognition and further testing of liver enzymes (AST, ALT) are critical for diagnosis and management.

Rationale for incorrect Response 1 options:
Chorioamnionitis is an infection of the amniotic sac, usually presenting with fever, uterine tenderness, and elevated WBC, which are not present here. Gestational diabetes is characterized by hyperglycemia, but the client’s blood glucose is only mildly elevated and not diagnostic. Pyelonephritis involves urinary tract infection with systemic symptoms like fever and flank pain, absent in this case.

Rationale for incorrect Response 2 options:
Amniotic membrane status is unrelated here, as there is no rupture or infection evidence. Ketonuria reflects starvation or diabetes, which is not indicated. Blood glucose is only mildly elevated and insufficient to diagnose gestational diabetes or explain current symptoms.

Take home points:

• HELLP syndrome involves low platelets, elevated liver enzymes, and hemolysis, often with epigastric pain.
• Early lab monitoring including liver enzymes is vital for timely diagnosis.
• Elevated BUN, creatinine, and uric acid can signal renal impairment in HELLP.
• Differentiate HELLP from infections or gestational diabetes by clinical presentation and specific labs.