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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Epigastric pain and nausea.This is because epigastric pain and nausea are signs of severe preeclampsia that indicate liver involvement and possible hepatic rupture.

This is a medical emergency that requires immediate intervention to prevent maternal and fetal complications.

Choice A is wrong because contractions lasting 90 seconds and occurring every 2 minutes are normal during labor induction with oxytocin and do not indicate severe preeclampsia.

Choice B is wrong because fetal heart rate baseline of 140/min with moderate variability is a reassuring sign of fetal well-being and does not indicate severe preeclampsia.

Choice C is wrong because cervical dilation of 4 cm and effacement of 50% are normal findings during labor induction and do not indicate severe preeclampsia.

A. Deep tendon reflexes B. Respiratory rate C. Urine output D. Fetal heart rate E. Serum magnesium level

Correct Answer is ["A","B","C","E"]

Explanation

The correct answer is choice A, B, C and E.The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV.Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest.The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.

Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity.However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.

Normal ranges for the assessments are:

• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)

• Respiratory rate: 12 to 20 breaths per minute

• Urine output: at least 30 mL per hour

• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is D

Explanation

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following actions should the nurse take before giving the medication? (Select all that apply.)

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A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia. Which of the following outcomes indicates that the therapy is successful?

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (Select all that apply.)

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following results should the nurse notify the provider about? (Select all that apply.)

A nurse is caring for a client with eclampsia who is receiving magnesium sulfate and has a magnesium level of 10 mg/dL. Which of the following medications should the nurse have available as an antidote?

A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

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.)