The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin (Pitocin) infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransferase (AST) level, and a falling hematocrit. The laboratory results are indicative of which condition?

Disseminated intravascular coagulation (DIC) syndrome

Eclampsia

Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome

Idiopathic thrombocytopenia

Answer and Explanation

The Correct Answer is C

Choice A reason: Disseminated intravascular coagulation (DIC) syndrome is not the correct answer, as it is a coagulation disorder that causes widespread clotting and bleeding in the body. DIC can occur as a complication of severe preeclampsia, but it is not indicated by the laboratory results. DIC would cause a low platelet count, but also a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), and a low fibrinogen level.

Choice B reason: Eclampsia is not the correct answer, as it is a seizure disorder that occurs in clients with severe preeclampsia. Eclampsia can occur as a complication of severe preeclampsia, but it is not indicated by the laboratory results. Eclampsia would cause a high blood pressure, but also a proteinuria, edema, and hyperreflexia.

Choice C reason: Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome is the correct answer, as it is a variant of severe preeclampsia that affects the blood and the liver. HELLP syndrome is indicated by the laboratory results, as it causes a low platelet count, an elevated AST level, and a falling hematocrit. HELLP syndrome would also cause a high blood pressure, a proteinuria, and a right upper quadrant pain.

Choice D reason: Idiopathic thrombocytopenia is not the correct answer, as it is an autoimmune disorder that causes the destruction of platelets by antibodies. Idiopathic thrombocytopenia can affect pregnant women, but it is not related to severe preeclampsia or the laboratory results. Idiopathic thrombocytopenia would cause a low platelet count, but not an elevated AST level or a falling hematocrit.

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Correct Answer is B

Explanation

Choice A reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause fetal distress, growth restriction, or demise. Continuous fetal monitoring can help detect and evaluate the fetal heart rate, variability, accelerations, decelerations, and contractions, and guide the management and intervention.

Choice B reason: This order requires clarification, as it is an inappropriate and contraindicated order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause seizures, stroke, or organ failure. Ambulation can increase the blood pressure, stimulate the labor, and worsen the condition. The client should be on bed rest, with the head of the bed elevated, and receive medications to lower the blood pressure and prevent seizures.

Choice C reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause edema, proteinuria, or oliguria. Obtaining a daily weight can help monitor the fluid status, the severity of the edema, and the response to the treatment.

Choice D reason: This order does not require clarification, as it is an appropriate and standard order for a client who has severe preeclampsia, which is a hypertensive disorder of pregnancy that can cause hyperreflexia, clonus, or seizures. Assessing deep tendon reflexes every hour can help evaluate the neuromuscular irritability, the risk of eclampsia, and the effect of magnesium sulfate.

A. AFI B. Fetal heart rate C. Fetal movement D. Fetal tone E. Placental grade

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: AFI stands for amniotic fluid index, which is a measurement of the amount of amniotic fluid surrounding the fetus. AFI is an indicator of fetal well-being, as it reflects the fetal urine output and the placental function. A normal AFI is between 5 and 25 cm. A low AFI (< 5 cm) can suggest fetal growth restriction, oligohydramnios, or fetal distress. A high AFI (> 25 cm) can suggest fetal anomalies, polyhydramnios, or maternal diabetes.

Choice B reason: Fetal heart rate is an assessment of the fetal cardiac activity, which is usually monitored by a non-stress test (NST). Fetal heart rate is an indicator of fetal well-being, as it reflects the fetal oxygenation and the autonomic nervous system. A normal fetal heart rate is between 110 and 160 beats per minute, with moderate variability and accelerations. A non-reactive fetal heart rate (< 2 accelerations in 20 minutes) can suggest fetal hypoxia, acidosis, or distress.

Choice C reason: Fetal movement is an assessment of the fetal gross body movements, which are usually counted by the mother or observed by ultrasound. Fetal movement is an indicator of fetal well-being, as it reflects the fetal activity and the central nervous system. A normal fetal movement is at least 3 movements in 30 minutes. A decreased fetal movement (< 3 movements in 2 hours) can suggest fetal sleep, sedation, or distress.

Choice D reason: Fetal tone is an assessment of the fetal muscle tone, which is usually observed by ultrasound. Fetal tone is an indicator of fetal well-being, as it reflects the fetal maturity and the neuromuscular system. A normal fetal tone is at least 1 episode of fetal flexion or extension in 30 minutes. An abnormal fetal tone (absent or hypotonic) can suggest fetal immaturity, anomalies, or distress.

Choice E reason: Placental grade is not an assessment that is included in the fetal biophysical profile (BPP), as it is not a direct measure of fetal well-being, but rather a classification of the placental maturity and calcification. Placental grade is usually evaluated by ultrasound, and it ranges from 0 to 3, with higher grades indicating more calcification and aging. Placental grade can affect the placental function and the fetal growth, but it is not a reliable or consistent indicator of fetal distress.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

Correct Answer is B

Explanation

Which assessments are included in the fetal biophysical profile (BPP)? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has been diagnosed with hyperemesis gravidarum. Which of the following is not a risk factor for hyperemesis gravidarum?

A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse?

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 11 lb 6 oz. (5160 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful?