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.
Petechiae.
Jaundice.
4+ deep tendon reflexes.
3+ pitting edema.
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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Correct Answer is B
Explanation
Choice A rationale
Swaddling provides warmth but doesn't address jitteriness, which may be due to hypoglycemia.
Choice B rationale
Jitteriness in a newborn can indicate hypoglycemia. Prompt glucose assessment is crucial for early detection and management.
Choice C rationale
Feeding could help with glucose levels, but without knowing the glucose status, it might not be the immediate priority.
Choice D rationale
Routine medications are important but not as urgent as addressing possible hypoglycemia in a jittery baby.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
Hypertensive disorders, such as preeclampsia, increase the risk of placental abruption. They can cause changes in the blood vessels of the placenta, reducing blood flow and increasing the likelihood of separation.
Choice B rationale
Uterine fibroids, which are noncancerous growths in the uterus, can interfere with the proper attachment of the placenta, raising the risk of placental abruption.
Choice C rationale
Cigarette smoking contributes to placental abruption by reducing oxygen supply to the placenta, causing placental insufficiency and increasing the risk of premature separation.
Choice D rationale
Abdominal trauma, such as from a fall or car accident, can cause mechanical disruption of the placenta, leading to abruption.
Choice E rationale
Methamphetamine use can cause vasoconstriction and hypertension, which compromise placental blood flow and increase the risk of abruption.