A nurse is caring for a female client, age 32, at 28 weeks of gestation, admitted to the antepartum unit with a diagnosis of HELLP syndrome.
The nurse is assessing the client 15 minutes later. For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client’s condition is improving, or an indication that the client’s condition is worsening.
Moderate maternal bleeding
Client reports ringing in ears
BP 180/100 mm Hg
Client reports sharp, stabbing abdominal pain
FHR 80/min with absent variability
PT 12 seconds
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
- Moderate maternal bleeding: Worsening condition. HELLP syndrome involves platelet consumption and liver dysfunction that can cause coagulopathy and bleeding risk. New or increased bleeding signals disease progression and possible disseminated intravascular coagulation (DIC).
- Client reports ringing in ears: Worsening condition. Tinnitus can be a sign of hypertensive encephalopathy or central nervous system involvement from severe preeclampsia/HELLP, indicating neurological deterioration.
- BP 180/100 mm Hg: Worsening condition. A significant increase from baseline hypertension signals uncontrolled blood pressure and heightened risk for stroke, organ damage, and progression of HELLP.
- Client reports sharp, stabbing abdominal pain: Worsening condition. This could indicate hepatic hematoma or infarction, a serious complication of HELLP syndrome due to liver injury.
- FHR 80/min with absent variability: Worsening condition. Fetal bradycardia with absent variability indicates fetal distress, often from placental insufficiency related to maternal vascular compromise.
- PT 12 seconds: Indication of improving condition. Normal prothrombin time (PT range ~11-13.5 seconds) suggests stable coagulation status, indicating no worsening coagulopathy or bleeding tendency at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Depression is a common mental health condition and is not a contraindication for the use of a copper intrauterine device (IUD). The copper IUD is a non-hormonal contraceptive method, meaning it does not release hormones that could potentially interact with or exacerbate symptoms of depression. Therefore, it is a safe option for individuals with this condition.
Choice B rationale
Diabetes mellitus, when well-controlled, is not a contraindication for the use of a copper IUD. The copper IUD does not affect blood glucose levels or insulin sensitivity, making it a suitable contraceptive option for individuals with diabetes. Hormonal methods might require more careful consideration, but copper IUDs are generally safe.
Choice C rationale
Cholelithiasis, or gallstones, is a condition affecting the gallbladder and bile ducts. It is not a contraindication for the use of a copper IUD. The copper IUD's mechanism of action is local, primarily affecting the uterine environment, and does not involve systemic hormonal changes that would impact gallbladder function.
Choice D rationale
Dysmenorrhea, or painful menstruation, is a significant contraindication for the use of a copper IUD. The copper IUD is known to increase menstrual bleeding and cramping, which can worsen pre-existing dysmenorrhea. This potential exacerbation of symptoms can lead to client dissatisfaction and discontinuation of the method.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Vacuum-assisted delivery increases the risk of postpartum hemorrhage due to potential trauma to the birth canal and uterine atony caused by prolonged pressure or rapid extraction. The vacuum device can bruise the cervix, vagina, or perineum, leading to lacerations that bleed excessively. It can also overstretch uterine muscles, impairing their ability to contract effectively after birth.
Choice B rationale
A newborn weight of 2.948 kg (6 lb 8 oz) is within the normal weight range for a full-term infant. This weight does not typically pose an increased risk for postpartum hemorrhage. Larger infants (macrosomia, generally > 4 kg) are associated with higher risks due to increased uterine stretching and potential for prolonged labor or birth trauma.
Choice C rationale
Labor induction with oxytocin significantly increases the risk for postpartum hemorrhage, particularly due to uterine atony. Prolonged oxytocin administration can lead to desensitization of myometrial receptors, reducing the uterus's ability to contract effectively postpartum. This impaired contractility prevents compression of uterine blood vessels, resulting in excessive bleeding.
Choice D rationale
A history of uterine atony is a substantial risk factor for recurrent postpartum hemorrhage. Uterine atony is the most common cause of postpartum hemorrhage, accounting for a majority of cases. A prior history indicates a predisposition for the uterine musculature to fail in contracting adequately after birth, leading to uncontrolled blood loss.
Choice E rationale
A history of human papillomavirus (HPV) infection does not directly increase the risk of postpartum hemorrhage. HPV is a viral infection that primarily affects epithelial cells, often leading to genital warts or cervical dysplasia. It does not inherently alter uterine contractility, coagulation factors, or predispose to abnormal placental implantation, which are direct causes of hemorrhage.
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