A nurse is caring for a client who has a diagnosis of HELLP syndrome.
The nurse should monitor the client for which of the following complications? (Select all that apply.)
Disseminated intravascular coagulation (DIC)
Acute kidney injury
Pulmonary edema
Placental abruption
Fetal growth restriction
Correct Answer : A,C,D,E
The correct answer is choice A, C, D and E. Here is why:
• Choice A is correct because disseminated intravascular coagulation (DIC) is a blood clotting disorder that can develop as a complication of HELLP syndrome. DIC can result in excessive bleeding or blood clots in various organs.
• Choice B is wrong because acute kidney injury is not a common complication of HELLP syndrome. However, preeclampsia can cause kidney damage and proteinuria (high levels of protein in the urine).
• Choice C is correct because pulmonary edema is a condition where fluid accumulates in and around the lungs, impairing oxygen absorption. It can occur as a complication of HELLP syndrome due to high blood pressure and fluid overload.
• Choice D is correct because placental abruption is a condition where the placenta separates from the uterus before delivery.
It can cause severe bleeding and fetal distress. It can occur as a complication of HELLP syndrome due to high blood pressure and abnormal blood clotting.
• Choice E is correct because fetal growth restriction is a condition where the fetus does not grow as expected. It can occur as a complication of HELLP syndrome due to reduced blood flow and oxygen delivery to the placenta.
Normal ranges for liver enzymes are:
• Alanine aminotransferase (ALT): 7 to 55 units per liter (U/L)
• Aspartate aminotransferase (AST): 8 to 48 U/L
• Alkaline phosphatase (ALP): 45 to 115 U/L
Normal range for platelet count is:
• 150,000 to 450,000 platelets per microlitre.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Respiratory rate 10/min.This indicatesmuscle weaknessanddifficulty breathing, which are symptoms ofmagnesium toxicity.Magnesium sulfate is a medication that can cause magnesium overdose if given in excess or if the patient has impaired kidney function.
Choice B.Urine output 40 mL/hr is wrong because this is within the normal range for urine output, which is 30 to 50 mL/hr.Urine output may decrease in severe cases of magnesium toxicity due to urine retention.
Choice C. Patellar reflex 2+ is wrong because this is a normal finding for the knee-jerk reflex.A low or absent patellar reflex may indicate magnesium toxicity, as it reflectsmuscle weaknessandnerve dysfunction.
Choice D.Serum magnesium level 4.5 mEq/L is wrong because this is within the normal range for serum magnesium, which is 1.7 to 2.3 mEq/L.Serum magnesium levels above 2.6 mEq/L can indicate hypermagnesemia or magnesium overdose.
Correct Answer is A
Explanation
Calcium gluconate is the antidote for magnesium sulfate toxicity because it reverses the effects of magnesium on the neuromuscular and cardiovascular systems.
Magnesium sulfate can cause respiratory depression, hypotension, bradycardia, and cardiac arrest in high doses.
Choice B. Naloxone is wrong because it is the antidote for opioid overdose, not magnesium sulfate toxicity.
Naloxone blocks the opioid receptors and restores breathing and consciousness.
Choice C. Flumazenil is wrong because it is the antidote for benzodiazepine overdose, not magnesium sulfate toxicity.
Flumazenil binds to the benzodiazepine receptors and reverses the sedative and hypnotic effects.
Choice D. Protamine sulfate is wrong because it is the antidote for heparin overdose, not magnesium sulfate toxicity.
Protamine sulfate neutralizes the anticoagulant effect of heparin and prevents bleeding.
Normal ranges for magnesium are 1.5 to 2.5 mEq/L or 0.75 to 1.25 mmol/L.
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