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 A
Explanation
Choice A rationale
Massaging the fundus can help contract the uterus and reduce bleeding. Ensuring IV access is crucial for administering medications rapidly. Methylergonovine (Methergine) and oxytocin help stimulate uterine contractions and reduce postpartum hemorrhage, which can be life-threatening.
Choice B rationale
Administering pain medication might be necessary, but it doesn't address the immediate issue of uterine atony and hemorrhage. Surgical intervention is a last resort and should be prepared for only if medical management fails.
Choice C rationale
Reassessing vital signs and monitoring is important, but it doesn't provide an immediate solution to the bleeding and uterine atony. Immediate action to contract the uterus is crucial.
Choice D rationale
Contacting the attending physician is important, but immediate intervention to stop the bleeding and address uterine atony is critical to prevent further complications.
Correct Answer is D
Explanation
Choice A rationale
Reflexes of 3+ indicate hyperreflexia, common in pre-eclampsia, but not necessarily critical. Monitoring is essential but not an emergency.
Choice B rationale
Urinary output of 30 mL/hr is within the acceptable range but requires monitoring for any changes. It's not a critical alert.
Choice C rationale
A respiratory rate of 16 rpm is normal and does not indicate immediate risk requiring physician notification.
Choice D rationale
Serum magnesium level of 10 mg/dL is significantly high, indicating potential toxicity. Immediate physician notification is critical to adjust magnesium sulfate administration.