A nurse is reviewing the electronic medical record of a female client, age 31, at 36 weeks of gestation in the antepartum unit.
Complete the following sentence by using the lists of options.
After reviewing the information in the client’s EMR, the nurse determines that the client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The client is at risk for developing HELLP syndrome as evidenced by Liver enzymes.
Rationale for correct answers:
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe form of preeclampsia often presenting in the third trimester. This client has thrombocytopenia (platelets 100,000/mm³; normal 150,000–400,000/mm³), elevated blood urea nitrogen (25 mg/dL; normal 10–20 mg/dL), borderline elevated creatinine (1.1 mg/dL; normal 0.5–1.0 mg/dL), and elevated uric acid (9.8 mg/dL; normal 2.7–7.3 mg/dL), which suggests possible renal impairment and oxidative stress typical in HELLP. Mild epigastric discomfort also aligns with liver involvement. Although liver enzymes are not listed in the labs here, the question implies liver enzyme elevation as a hallmark finding to confirm HELLP, which is essential to monitor. Hemolysis would typically manifest as anemia, but hemoglobin and hematocrit are near normal. Prompt recognition and further testing of liver enzymes (AST, ALT) are critical for diagnosis and management.
Rationale for incorrect Response 1 options:
Chorioamnionitis is an infection of the amniotic sac, usually presenting with fever, uterine tenderness, and elevated WBC, which are not present here. Gestational diabetes is characterized by hyperglycemia, but the client’s blood glucose is only mildly elevated and not diagnostic. Pyelonephritis involves urinary tract infection with systemic symptoms like fever and flank pain, absent in this case.
Rationale for incorrect Response 2 options:
Amniotic membrane status is unrelated here, as there is no rupture or infection evidence. Ketonuria reflects starvation or diabetes, which is not indicated. Blood glucose is only mildly elevated and insufficient to diagnose gestational diabetes or explain current symptoms.
Take home points:
- HELLP syndrome involves low platelets, elevated liver enzymes, and hemolysis, often with epigastric pain.
- Early lab monitoring including liver enzymes is vital for timely diagnosis.
- Elevated BUN, creatinine, and uric acid can signal renal impairment in HELLP.
- Differentiate HELLP from infections or gestational diabetes by clinical presentation and specific labs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Avoiding sterile vaginal examinations is not a primary action for uterine atony and large vaginal bleeding. While excessive or repeated vaginal examinations can potentially introduce infection or dislodge clots, the immediate priority for uterine atony is to address the lack of uterine tone to prevent further blood loss.
Choice B rationale
Obtaining a specimen for a Kleihauer-Betke test is used to quantify the amount of fetal red blood cells in the maternal circulation, typically after a significant feto-maternal hemorrhage or trauma. While potentially useful in specific situations, it is not an immediate, primary intervention for acute uterine atony and bleeding.
Choice C rationale
Performing a fundal massage is the most immediate and critical action for uterine atony. Uterine atony is the leading cause of postpartum hemorrhage, characterized by a boggy, relaxed uterus that cannot effectively constrict blood vessels at the placental site. Manual massage stimulates uterine contractions, promoting vasoconstriction and reducing blood loss.
Choice D rationale
Assessing for abdominal tenderness is an important assessment, but it is not the primary intervention for acute uterine atony with large vaginal bleeding. Abdominal tenderness could indicate other complications such as uterine rupture or hematoma, which require different immediate interventions after addressing the atony.
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.
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