Exhibits

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings? 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.

Explanation

1. Moderate maternal bleeding
   • In a patient with HELLP and thrombocytopenia, bleeding suggests coagulopathy (DIC) or placental abruption. This is a serious worsening sign.
2. Ringing in ears (tinnitus)
   • Could be a side effect of magnesium sulfate toxicity or a neurological symptom of worsening preeclampsia. Either way, it’s concerning and not a sign of improvement.
3. Sharp, stabbing abdominal pain
   • RUQ/epigastric pain worsening into sharp pain raises concern for liver capsule distension or rupture (life-threatening complication of HELLP) or placental abruption. This is a red flag.
4. BP 180/100 mm Hg
   • Despite antihypertensive therapy, this is severe hypertension (≥160/110 mm Hg). Indicates poor control and worsening maternal risk.
5. FHR 80/min with absent variability
   • This is severe fetal bradycardia with no variability, indicating fetal hypoxia/distress. This is an obstetric emergency.
6. PT 12 seconds
   • Within normal range (11–13.5 sec). This suggests no current coagulopathy and is the only stable/improving finding.

Almost all findings point to worsening maternal and fetal condition, except for the PT which is stable. The nurse should immediately notify the provider, anticipate emergency delivery (likely induction or cesarean), and continue close monitoring for magnesium toxicity and bleeding complications.

Choice A rationale

A fetal heart rate (FHR) of 150/min with moderate variability is within the normal range (110-160/min) and suggests adequate fetal oxygenation, which is less indicative of a significant Grade 2 abruption. A Grade 2 (moderate) abruption typically involves 20%-50% placental separation, often resulting in fetal distress like persistent late decelerations or tachycardia as a compensatory response to hypoxemia.

Choice B rationale

Placenta previa, not abruption, classically presents with painless, bright red vaginal bleeding due to the placenta covering the cervical os. Placental abruption, caused by premature separation of the placenta from the uterine wall, typically causes bleeding accompanied by significant, severe, and unrelenting abdominal pain due to concealed hemorrhage and uterine irritability.

Choice C rationale

A soft abdomen suggests a relaxed uterus, which is normal. In Grade 2 placental abruption, blood often becomes trapped between the placenta and uterine wall, causing uterine tetany or hypertonicity (increased muscle tone) and rigidity, which presents as a firm or board-like abdomen that is tender to palpation.

Choice D rationale

A heart rate of 120/min (tachycardia) in the client is an expected finding in a moderate (Grade 2) placental abruption. The client is experiencing hypovolemia due to hemorrhage (internal and/or external bleeding), which triggers a compensatory sympathetic nervous system response, increasing the heart rate to maintain cardiac output and tissue perfusion.