The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

Weight gain and shortness of breath

Epigastric pain and elevated liver enzymes

Edema of hands and feet of +2

Fatigue and headache

Answer and Explanation

The Correct Answer is B

A. Weight gain and shortness of breath are common symptoms of pre-eclampsia or hypertension, but they are not specific to HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets). Shortness of breath could be due to other conditions, such as pulmonary edema, but it does not directly indicate HELLP syndrome.

B. Epigastric pain and elevated liver enzymes is a classic symptom of HELLP syndrome, a severe form of pregnancy-induced hypertension (PIH). The epigastric pain is often related to liver distention due to the liver damage and elevated liver enzymes. This is a key indicator of HELLP syndrome, which can be life-threatening if not managed promptly.

C. Edema of hands and feet of +2 is a common finding in pregnancy-related hypertension or pre-eclampsia but is not specific to HELLP syndrome. Mild edema (such as +2) can occur in many pregnancies and does not necessarily indicate the severity of the condition.

D. Fatigue and headache are symptoms commonly seen in pre-eclampsia and may also occur in HELLP syndrome, but they are less specific compared to epigastric pain and elevated liver enzymes, which are hallmark signs of HELLP syndrome.

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Correct Answer is A

Explanation

A. The client talks frequently about her labor and delivery is a characteristic behavior of the Taking In phase, which occurs during the first few days postpartum. During this phase, the mother is primarily focused on her own needs and recovering from childbirth. She may want to discuss her labor and delivery experience and may be more focused on rest and reflection rather than engaging with the baby.

B. The client hesitates to initiate contact with the baby is more characteristic of the Taking Hold phase, which comes after the Taking In phase. In the Taking Hold phase, the mother begins to take more responsibility for her baby’s care, though she may still seek guidance.

C. The client questions the nurse about the amount of formula for the baby indicates a more active engagement in learning about infant care, which is typical of the Taking Hold phase, where the mother starts to focus on baby care and becomes more involved.

D. The client requests between meals snacks is a sign of physical recovery and possibly an increased need for nourishment, but it does not specifically indicate being in the Taking In phase. This behavior may occur in any phase but is not a defining characteristic.

A. Increase in dietary protein B. Schedule a repeat Glucose challenge test (GCT) C. Restrict carbohydrate intake D. Return for a fasting 3-hour glucose tolerance test (GTT)

Correct Answer is D

Explanation

A. Increase in dietary protein is not the appropriate response based on the results of the glucose challenge test. Protein intake may be adjusted for other health reasons but is not typically a first-line intervention after an abnormal GCT result.

B. Schedule a repeat Glucose Challenge Test (GCT) is not typically the next step. If the initial GCT is abnormal (usually a result >130-140 mg/dL), a repeat test is not recommended. Instead, a 3-hour glucose tolerance test (GTT) is used to confirm or rule out gestational diabetes.

C. Restrict carbohydrate intake might be part of managing gestational diabetes if it is diagnosed, but it is not the immediate next step after an abnormal GCT result. The focus is on further testing with a 3-hour GTT to confirm gestational diabetes.

D. Return for a fasting 3-hour glucose tolerance test (GTT) is the correct next step. If a client’s GCT result is ≥130-140 mg/dL, a 3-hour GTT is typically scheduled. The 3-hour GTT is a more comprehensive test that involves fasting and measuring blood glucose levels after consuming a larger dose of glucose (100 g). This test is used to diagnose gestational diabetes.

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The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

Correct Answer is A

Explanation

A 26-week pregnant client has a Glucose challenge test (GCT) with 50 g of glucola, her results are 150mg/dl. What would be expected next step when caring for this client?

Correct Answer is D

Explanation

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