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 C

Explanation

This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.

The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.

Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.

Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe.Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.

Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia.Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.

A. Administer oxygen via face mask B. Turn the client to the side C. Insert an oral airway D. Give a loading dose of magnesium sulfate

Correct Answer is B

Explanation

Turn the client to the side.This is because turning the client to the side will prevent aspiration of secretions or vomitus and maintain a patent airway during a seizure.

This is the most important and immediate action to take for a client with eclampsia who is having a tonic-clonic seizure.

Choice A is wrong because administering oxygen via face mask is not the first priority and may not be feasible during a seizure.Oxygen therapy may be indicated after the seizure to improve oxygenation and fetal well-being.

Choice C is wrong because inserting an oral airway is contraindicated during a seizure as it may cause injury to the oral mucosa or trigger a gag reflex.An oral airway may be used after the seizure if the client is unconscious and has a compromised airway.

Choice D is wrong because giving a loading dose of magnesium sulfate is not the first action to take, although it is an important intervention to prevent further seizures and lower blood pressure in eclampsia.Magnesium sulfate should be administered intravenously after securing the airway and ensuring adequate ventilation.

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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 assessing a client who is 24 weeks pregnant and has preeclampsia. Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

Correct Answer is C

Explanation

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

Correct Answer is B

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.

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?

A nurse is caring for a client with severe pre-eclampsia who is receiving magnesium sulfate. Which assessment finding would indicate that the client is experiencing magnesium toxicity?

A nurse is educating a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously about the possible side effects of the medication. Which of the following statements should the nurse include in the teaching?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

(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 providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

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.)