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.

Choice A rationale

Nausea, commonly known as "morning sickness," is a very common and normal physiological response during the first trimester of pregnancy, often attributed to hormonal changes, particularly rising levels of human chorionic gonadotropin (hCG) and estrogen. While uncomfortable, it does not typically indicate a need for a registered dietitian referral unless it leads to significant weight loss or hyperemesis gravidarum.

Choice B rationale

A 4.5 kg (10 lb) weight gain by 12 weeks of gestation is considered excessive for the first trimester. The recommended weight gain during the first trimester is typically 0.5 to 2 kg (1 to 4.5 lb). Such rapid weight gain can indicate an imbalanced diet or underlying nutritional issues that warrant evaluation and guidance from a registered dietitian to optimize maternal and fetal health.

Choice C rationale

Taking a multivitamin daily, especially one formulated for prenatal use, is a positive health behavior during pregnancy. Prenatal vitamins typically contain essential nutrients like folic acid and iron, which are crucial for fetal development and maternal health, reducing the risk of neural tube defects and iron deficiency anemia. This indicates appropriate nutritional supplementation, not a need for referral.

Choice D rationale

Constipation is a common complaint during pregnancy, often due to hormonal changes, such as increased progesterone, which slows gastrointestinal motility, and pressure from the growing uterus on the bowels. Eating prunes is a natural and effective dietary strategy to manage constipation, as they are a good source of fiber, promoting bowel regularity. This is a healthy coping mechanism and does not necessitate a dietitian referral.

Choice A rationale: Blood pressure readings below 160/110 mm Hg overnight indicate some level of blood pressure control, which is a positive sign in hypertensive pregnancy conditions. The goal is to maintain pressures below this threshold to reduce risk of end-organ damage. Stable or lower pressures reduce cerebral and placental ischemia risk. Therefore, resting well with controlled BP suggests no immediate worsening, indicating progression is stable at this point.

Choice B rationale: A decrease in headache intensity temporarily is a favorable clinical sign. Headache in preeclampsia is caused by cerebral edema and vasospasm, so improvement indicates less neurological irritation or pressure. However, this is a transient improvement and must be interpreted cautiously, but the reduction alone does not indicate a worsening condition, so it is not a marker of poor progression.

Choice C rationale: An increased headache intensity rating to 7/10 signals significant neurological involvement and increased cerebral irritation, typical of worsening preeclampsia or impending eclampsia. Severe headaches in pregnancy with hypertension indicate cerebral vasospasm or edema, which may lead to seizures if untreated. This is a critical sign requiring urgent intervention to prevent maternal and fetal morbidity.

Choice D rationale: Persistent visual disturbances such as seeing spots or flashes are neurological symptoms indicating retinal or cerebral involvement due to vasospasm, ischemia, or edema. These symptoms are common in severe preeclampsia and herald worsening disease. Visual symptoms result from endothelial dysfunction affecting cerebral and retinal vessels, requiring immediate evaluation to prevent progression to eclampsia.

Choice E rationale: Epigastric discomfort reflects stretching or ischemia of the liver capsule from hepatic involvement in severe preeclampsia or HELLP syndrome. This pain typically presents as right upper quadrant or epigastric pain due to hepatocellular injury or microvascular thrombosis. It is a warning sign of multisystem involvement and potential progression to life-threatening complications such as hepatic rupture.

Choice F rationale: Hyperactive deep tendon reflexes (3+ to 4+) and positive clonus are clinical signs of central nervous system irritability caused by increased excitability of motor neurons. This occurs due to cerebral vasospasm and ischemia in severe preeclampsia and predicts risk for seizures (eclampsia). These neurological signs are crucial in assessing disease severity and necessitate urgent management.

Choice G rationale: Urine output between 25 and 55 mL/hr approaches the lower limit of normal (normal ≥30 mL/hr). Reduced urine output in preeclampsia indicates renal hypoperfusion or injury due to endothelial dysfunction and vasospasm, which can progress to acute kidney injury. Monitoring urine output is essential as oliguria signals worsening renal compromise, increasing maternal and fetal risk.