A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

disseminated intravascular coagulation (DIC)

elevated platelet count

elevated liver enzymes

hyperglycemia

Answer and Explanation

The Correct Answer is C

A. Disseminated intravascular coagulation (DIC):

DIC is a serious condition characterized by abnormal clotting throughout the body's blood vessels, leading to both bleeding and clotting simultaneously. While it can occur in severe cases of HELLP syndrome, it is not a specific finding used to diagnose HELLP syndrome. Instead, it's a complication that can develop due to various underlying conditions, including HELLP syndrome.

B. Elevated platelet count:

In HELLP syndrome, platelet count is typically decreased, not elevated. HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. The low platelet count is a key diagnostic feature of HELLP syndrome and contributes to the risk of bleeding complications.

C. Elevated liver enzymes:

Elevated liver enzymes, particularly elevated levels of AST (aspartate aminotransferase) and ALT (alanine aminotransferase), are hallmark features of HELLP syndrome. Liver involvement is a significant component of this syndrome, and elevated liver enzymes are part of the diagnostic criteria.

D. Hyperglycemia:

While hyperglycemia can occur in various conditions, it is not a characteristic finding of HELLP syndrome. HELLP syndrome primarily affects the liver, blood clotting factors, and platelets, leading to features such as elevated liver enzymes, low platelet count, and hemolysis (destruction of red blood cells).

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Correct Answer is A

Explanation

A. Deep tendon reflexes 2+: Deep tendon reflexes are typically assessed to monitor for signs of magnesium sulfate toxicity. A normal finding of 2+ deep tendon reflexes suggests that the client is not experiencing magnesium sulfate toxicity. However, it does not specifically indicate whether the medication is at a therapeutic level.

B. Respiratory rate of 10 breaths/minute: A respiratory rate of 10 breaths/minute is below the normal range, and it could indicate respiratory depression, a potential side effect of magnesium sulfate toxicity. While this finding suggests a potential adverse reaction to the medication, it does not confirm whether the medication is at a therapeutic level.

C. Urinary output of 20 mL per hour: Adequate urinary output is essential for excreting magnesium sulfate and preventing toxicity. A urinary output of 20 mL per hour is within an acceptable range and suggests adequate renal function, which is important for maintaining therapeutic levels of the medication. However, it alone does not confirm whether the medication is at a therapeutic level.

D. Difficulty in arousing: Difficulty in arousing is a concerning sign of magnesium sulfate toxicity and suggests central nervous system depression. It indicates that the client may be experiencing an adverse reaction to the medication and that the dose may need adjustment. While this finding suggests a potential issue with medication dosing or toxicity, it does not confirm whether the medication is at a therapeutic level.

A. 24 hours before birth and 24 hours after birth B. at 28 weeks' gestation and again within 72 hours after birth C. at 32 weeks' gestation and immediately before discharge D. in the first trimester and within 2 hours of birth

Correct Answer is B

Explanation

A. 24 hours before birth and 24 hours after birth:

This option suggests administering Rho(D) immune globulin (RhIg) both before and after birth. However, the standard recommendation is to administer RhIg at 28 weeks' gestation and again within 72 hours after birth. Administering RhIg before birth in this manner is not a standard practice for preventing Rh isoimmunization.

B. At 28 weeks' gestation and again within 72 hours after birth:

This is the correct choice. Administering RhIg at 28 weeks' gestation helps prevent sensitization of the Rh-negative mother to Rh-positive fetal blood cells that may have entered her circulation during pregnancy. Administering it again within 72 hours after birth helps prevent sensitization from any Rh-positive fetal blood cells that may have entered the mother's circulation during delivery.

C. At 32 weeks' gestation and immediately before discharge:

Administering RhIg at 32 weeks' gestation is not the standard recommendation. The standard timing is at 28 weeks' gestation to cover the critical period of sensitization during pregnancy. Administering it immediately before discharge may not provide adequate protection if sensitization has already occurred during pregnancy.

D. In the first trimester and within 2 hours of birth:

Administering RhIg in the first trimester is not a routine practice unless there is a specific indication, such as miscarriage or invasive procedures that may lead to fetal-maternal hemorrhage. Administering it within 2 hours of birth alone does not provide adequate protection against sensitization during pregnancy. The standard recommendation is to administer RhIg at 28 weeks' gestation and again within 72 hours after birth to cover the critical periods of sensitization during pregnancy and delivery.

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A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

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Naxlex Comprehensive Predictor Exams

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is A

Explanation

It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

Correct Answer is B

Explanation

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