The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome?

elevated liver enzymes

elevated platelet count

leukocytosis

hyperglycemia

Answer and Explanation

The Correct Answer is A

A. Elevated liver enzymes is a key indicator of HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. HELLP syndrome is a severe form of preeclampsia and can lead to liver damage. Elevated liver enzymes, such as AST and ALT, are a hallmark of this condition, indicating liver dysfunction.

B. Elevated platelet count would be the opposite of what is expected in HELLP syndrome. In HELLP syndrome, there is typically low platelet count (thrombocytopenia), not an elevated one.

C. Leukocytosis refers to an increased white blood cell count, which can be indicative of an infection or inflammation, but it is not a hallmark of HELLP syndrome. HELLP syndrome primarily involves hemolysis, liver enzyme elevation, and low platelets.

D. Hyperglycemia is not a characteristic finding of HELLP syndrome. While it can occur in some pregnancy-related conditions, it is not specifically associated with HELLP syndrome. This condition is more associated with elevated liver enzymes and low platelets.

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Correct Answer is D

Explanation

A. Wrap the newborn in a blanket helps maintain body heat after the initial drying and stimulation but is not the first priority in thermoregulation.
B. Put a hat on the newborn's head also helps prevent heat loss, particularly from the head, which is a major site of heat loss in newborns. However, this should be done after drying to avoid trapping moisture.
C. Check the newborn's temperature is important but should be done after immediate measures to prevent heat loss have been taken.
D. Dry the newborn thoroughly is the first and most critical step in preventing evaporative heat loss, which is the primary cause of newborn heat loss immediately after birth. Removing wet amniotic fluid from the skin helps stabilize temperature effectively.

A. deficient fluid volume B. risk for infection C. impaired parenting D. hypothermia

Correct Answer is D

Explanation

A. Deficient fluid volume is not the priority concern at this time. While newborns are at risk for dehydration, there are no indications in the assessment (such as dry mucous membranes or poor feeding) that would suggest deficient fluid volume as the immediate priority.

B. Risk for infection is a concern for all newborns, especially in the first hours of life. However, the information provided does not suggest signs of infection such as fever, lethargy, or abnormal skin color.

C. Impaired parenting may be a concern later on if the parents show difficulty bonding or caring for the infant. However, this is not the immediate priority based on the infant's current assessment.

D. Hypothermia is the priority. The infant’s axillary temperature of 95.8° F (35.4° C) is below the normal range for a newborn, which is typically between 97.7° F (36.5° C) and 99.5° F (37.5° C). Hypothermia in newborns can lead to complications such as respiratory distress, metabolic instability, and increased risk for infection. Immediate interventions, such as warming the infant and ensuring a warm environment, are necessary to prevent further complications.

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The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome?

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Naxlex Comprehensive Predictor Exams

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

Correct Answer is D

Explanation

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

Correct Answer is D

Explanation

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