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 C

Explanation

A. Fluid replacement is important for maintaining maternal and fetal circulation, but it is not the priority immediately following a seizure. Oxygenation and stabilizing the mother’s condition are more critical in the acute phase.

B. Birth of the fetus may become necessary if the mother’s condition worsens, but the immediate priority is stabilizing the mother and ensuring proper oxygenation to prevent further complications for both the mother and fetus.

C. Oxygenation is the priority intervention after a seizure in eclampsia. Seizures can lead to a decrease in oxygen levels, and ensuring adequate oxygenation is crucial for both the mother and fetus. The nurse should administer oxygen to support breathing and prevent hypoxia.

D. Control of hypertension is essential in managing eclampsia, but the immediate focus should be on stabilizing the mother post-seizure, which includes ensuring adequate oxygenation first. Once stabilized, antihypertensive medications can be administered as necessary.

A. normal progression of behavior. B. probable hypoglycemia. C. physiological abnormality. D. inadequate oxygenation.

Correct Answer is A

Explanation

A. Newborns typically go through predictable behavioral states after birth. During the first period of reactivity, which lasts about 30–60 minutes after birth, the newborn is awake, alert, and active. This is followed by a period of sleep or decreased activity, which can last 2 to 4 hours. It is normal for the baby to be sleepy and difficult to awaken during this phase, especially around 2 hours of age.

B. Probable hypoglycemia could cause lethargy in a newborn, but it would typically be accompanied by other symptoms such as jitteriness, poor feeding, or abnormal vital signs. In a healthy 2-hour-old baby, sleepiness alone is not enough to suggest hypoglycemia.

C. Physiological abnormality is incorrect. There is no evidence of abnormality in a sleepy 2-hour-old newborn, as this is an expected part of the normal behavioral cycle after birth.

D. Inadequate oxygenation would likely present with signs such as cyanosis, abnormal respiratory rate, or poor perfusion, not just sleepiness.

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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 woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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