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Which of the following physical findings would lead the nurse to suspect that a client who has pre-eclampsia with severe features has developed HELLP syndrome? Select all that apply.

A.

Petechiae.

B.

Jaundice.

C.

4+ deep tendon reflexes.

D.

3+ pitting edema.

Question Solution

Correct Answer : A,B,D

Choice A rationale

Petechiae, small red or purple spots on the skin, indicate a low platelet count, which is a component of HELLP syndrome.

 

Choice B rationale

Jaundice, a yellowing of the skin and eyes, suggests liver involvement and hemolysis, both of which are features of HELLP syndrome.

 

Choice C rationale

4+ deep tendon reflexes are associated with severe pre-eclampsia but are not specific to HELLP syndrome.

 

Choice D rationale

3+ pitting edema, severe fluid retention causing swelling, can be a sign of HELLP syndrome, indicating liver or kidney involvement. .


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Induction timing is secondary to assessing readiness. The Bishop score determines cervical favorability for induction success.

Choice B rationale

The Bishop score assesses cervical readiness for labor induction, which is vital in planning an effective induction.

Choice C rationale

Refusal to induce without considering clinical data is inappropriate. The Bishop score evaluation determines readiness.

Choice D rationale

Prostaglandin preparation follows Bishop score assessment to ensure induction safety and efficacy.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.

Choice B rationale

Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.

Choice C rationale

Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.

Choice D rationale

Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.

Choice E rationale

Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.

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