Which symptom indicates increasing severity of pregnancy-induced hypertension and signs of HELLP syndrome?

Edema in hands and feet of +2

Fatigue and headache unrelieved by analgesic

Low platelets and elevated liver enzymes

Weight gain and shortness of breath

Answer and Explanation

The Correct Answer is C

A. Edema in hands and feet of +2: Peripheral edema is a common physiological finding in 80% of healthy pregnancies due to increased venous pressure. While it can occur in preeclampsia, it is no longer a diagnostic criterion for disease severity. It does not indicate the hematologic or hepatic dysfunction characteristic of HELLP.

B. Fatigue and headache unrelieved by analgesic: A persistent, severe headache is a premonitory sign of eclampsia and indicates central nervous system irritability. While this suggests worsening pregnancy-induced hypertension, it does not confirm the laboratory-defined triad of HELLP syndrome. This symptom requires immediate neurological and blood pressure stabilization.

C. Low platelets and elevated liver enzymes: The acronym HELLP stands for hemolysis, elevated liver enzymes, and low platelets. Thrombocytopenia and transaminitis indicate microangiopathic hemolytic anemia and hepatic necrosis. These laboratory markers are the definitive diagnostic criteria for this life-threatening multisystem complication.

D. Weight gain and shortness of breath: Rapid weight gain often reflects fluid retention, while dyspnea may signal the development of pulmonary edema in severe preeclampsia. These symptoms indicate cardiovascular and renal stress but are not specific to the HELLP triad. They necessitate urgent evaluation of cardiac and respiratory function.

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Correct Answer is A

Explanation

A. at the beginning of the second stage: This stage is defined by complete cervical dilation of 10 centimeters and 100% effacement. Pushing at this point utilizes the Ferguson reflex to facilitate fetal descent through the birth canal. It ensures the cervix is no longer an obstruction.

B. at the end of the active phase: This phase concludes when dilation reaches approximately 8 centimeters. Pushing before full dilation can cause cervical edema, maternal exhaustion, and potential cervical lacerations. The birth canal is not yet physiologically prepared for the forceful expulsion of the fetus.

C. during the latter part of the second stage: While pushing is necessary here, it must be initiated as soon as the stage starts to ensure progress. Waiting until the head is crowning or the stage is nearly over prolongs labor. Early coordination of contractions and pushing is optimal.

D. during transition: This represents the final part of the first stage of labor. Although the urge to push is intense, the cervix is not yet fully dilated. Premature pushing during transition increases the risk of maternal soft tissue trauma and fetal distress.

A. Open up the IV. B. Start oxygen per face mask. C. Stop the oxytocin infusion. D. Turn the client on her left side.

Correct Answer is C

Explanation

A. Open up the IV: Increasing the infusion of non-medicated fluids may improve maternal hydration and placental perfusion. However, this action does not stop the excessive uterine stimulation causing the hypertonicity. The primary pharmacological trigger must be addressed first to ensure safety.

B. Start oxygen per face mask: Administering oxygen helps mitigate fetal hypoxia resulting from reduced placental blood flow during prolonged contractions. This is a supportive measure rather than a corrective one. The source of the uterine tachysystole must be eliminated to restore normal perfusion.

C. Stop the oxytocin infusion: Hypertonic contractions significantly reduce oxygen exchange in the intervillous space. Discontinuing the exogenous oxytocin immediately decreases uterine muscle tone and prevents potential uterine rupture or fetal asphyxia. This is the most critical intervention to stop the adverse effect.

D. Turn the client on her left side: Lateral positioning helps maximize blood flow to the uterus by relieving pressure on the vena cava. While beneficial for fetal resuscitation, it cannot counteract the mechanical pressure of a hypertonic uterus. It is performed after stopping the medication infusion.

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Which symptom indicates increasing severity of pregnancy-induced hypertension and signs of HELLP syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse instructs the laboring client to begin pushing with her contractions

Correct Answer is A

Explanation

What is the nursing action that has the highest priority for a client experiencing hypertonic contractions during the use of oxytocin to stimulate labor?

Correct Answer is C

Explanation

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