A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.

What nursing interventions are appropriate for this client? Select all that apply.

Monitor vital signs and urine output

Administer corticosteroids as prescribed

Check for signs of fluid overload or transfusion reaction

Encourage oral intake of fluids and electrolytes

Maintain bed rest and a quiet environment

Answer and Explanation

Correct Answer : A,C

The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction. Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure. The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.

Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity. Corticosteroids may worsen the liver function and increase the risk of infection.

Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome. Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.

Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome. The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible. Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.

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

Explanation

The correct answer is choice A, C, D and E. Here is why:

• Choice A is correct becausedisseminated 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 becauseacute kidney injuryis 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 becausepulmonary edemais 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 becauseplacental abruptionis 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 becausefetal growth restrictionis 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.

A. Stop the magnesium sulfate infusion B. Increase the rate of the hydralazine infusion C. Administer calcium gluconate IV push D. Prepare for immediate delivery of the fetus

Correct Answer is A

Explanation

Stop the magnesium sulfate infusion.

The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.

Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.

The nurse should stop the infusion and monitor the client’s vital signs and neurological status.

Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.

The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.

Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.

It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.

Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.

The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.

Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.

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A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion. What nursing interventions are appropriate for this client? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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.)

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

Explanation

Correct Answer is A

Explanation

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 evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider as a sign of fetal compromise?

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

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 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?

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?

A nurse is reviewing the discharge instructions for a client who had severe preeclampsia and delivered her baby at 34 weeks of gestation by cesarean birth. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.

What nursing interventions are appropriate for this client? Select all that apply.