The nurse is assessing a 36-week gestation client who has been diagnosed with worsening preeclampsia and the nurse is concerned about HELLP syndrome.
The client's laboratory and assessment findings are as follows: AST 40 units/L, ALT 35 units/L, Hematocrit 21 percent, Hemoglobin 8 g/dL, BUN 15 mg/dL. Which finding is the priority to report to the provider?
ALT.
Hematocrit.
Hemoglobin.
BUN.
The Correct Answer is B
Evaluating maternal health in preeclampsia requires understanding HELLP syndrome, which involves hemolysis, elevated liver enzymes, and low platelets. Nurses must apply knowledge of hematologic shifts and normal lab ranges to identify life-threatening complications requiring immediate provider notification for patient safety.
Choice A rationale
Normal aspartate aminotransferase and alanine aminotransferase levels are typically 4 to 36 units/L. This value is within the upper normal range, indicating no significant hepatic cell destruction or inflammation characteristic of the HELLP syndrome triad.
Choice B rationale
Normal hematocrit for pregnant women exceeds 33 percent. A level of 21 percent indicates severe hemolysis or blood loss. In preeclampsia, this suggests microangiopathic hemolytic anemia, a critical component of HELLP syndrome requiring urgent intervention.
Choice C rationale
Normal hemoglobin during pregnancy is above 11 g/dL. While 8 g/dL is low, the hematocrit of 21 percent represents a more profound deviation from the three-to-one ratio, signifying more acute physiological instability regarding oxygen-carrying capacity.
Choice D rationale
Normal blood urea nitrogen levels range from 7 to 20 mg/dL. A value of 15 mg/dL is within normal limits, suggesting that renal filtration and perfusion remain adequate despite the systemic vasoconstriction common in worsening preeclampsia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Safe newborn feeding practices require applying knowledge of infant anatomy and physiology to prevent aspiration and gas distension. Proper technique involves positioning, air management, and gastric decompression to ensure nutritional intake while maintaining airway patency and gastrointestinal comfort.
Choice A rationale
Burping frequently removes swallowed air from the stomach, preventing gastric distension and reducing the risk of regurgitation or colic. It is a standard safety intervention to ensure the infant remains comfortable and digests the formula effectively.
Choice B rationale
Semi-upright positioning uses gravity to keep formula at the bottom of the stomach and air at the top. This reduces the risk of aspiration and reflux, providing a safer environment for swallowing compared to lying flat.
Choice C rationale
Placing a newborn in a supine position during feeding is dangerous because it significantly increases the risk of aspiration and choking. Formula can easily enter the trachea or flow into the eustachian tubes, causing ear infections.
Choice D rationale
Propping a bottle is contraindicated because it prevents the infant from controlling the flow, leading to overfeeding or choking. It also limits essential skin-to-skin contact and increases the risk of developing dental caries or infections.
Choice E rationale
Keeping the nipple full of formula ensures the infant sucks liquid rather than air. This technique minimizes aerophagia, which causes painful gas, bloating, and excessive spitting up, leading to a more efficient and comfortable feeding experience.
Correct Answer is C
Explanation
Neonatal resuscitation focuses on the transition to extrauterine life, emphasizing the ABCs. Nurses must apply knowledge of the Neonatal Resuscitation Program guidelines for a severely depressed infant. Prioritizing airway and ventilation is crucial for improving low Apgar scores.
Choice A rationale
Identification is a legal requirement for infant safety and security. However, in a resuscitation scenario with an Apgar score of 1, life-saving interventions like ventilation take immediate priority over administrative tasks such as applying identification bands.
Choice B rationale
Intravenous access allows for fluid volume expansion or medication delivery. While important for stabilization, it is secondary to establishing effective ventilation. Ventilation is the most critical step in improving heart rate and oxygenation in neonates.
Choice C rationale
An Apgar score of 1 indicates severe distress requiring immediate resuscitation. Preparing the bag and mask ensures that positive pressure ventilation can start immediately upon arrival. Establishing an airway and providing oxygen are the highest priorities.
Choice D rationale
Vitamin K and erythromycin are standard prophylactic treatments for newborns. These prevent bleeding and ophthalmia neonatorum, respectively. However, they are not urgent and should only be administered once the newborn is physiologically stable after resuscitation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.