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
Methylergonovine (Methergine) is used to manage postpartum hemorrhage by stimulating uterine contractions. It is especially useful in cases like this where rapid uterine tone is needed.
Choice B rationale
Magnesium sulfate is used to prevent seizures in preeclamptic patients, not to manage postpartum hemorrhage. This choice is incorrect in this context.
Choice C rationale
Carboprost-tromethamine (Hemabate) is also used for treating postpartum hemorrhage but is typically a secondary option to methylergonovine and may have more side effects.
Choice D rationale
Fresh frozen plasma (FFP) is used to replace clotting factors in cases of coagulopathy, not as a primary intervention for postpartum hemorrhage in this patient.
Correct Answer is B
Explanation
Choice A rationale
Prior amniotic fluid leakage is not a required criterion for amniotomy. The main concern is cervical readiness and fetal head position, not previous leakage.
Choice B rationale
The fetal head engaged in the maternal pelvis ensures proper pressure and position for safe amniotomy. Engagement reduces the risk of umbilical cord prolapse and injury.
Choice C rationale
Certification of the nurse for amniotomy is not a standard criterion. The procedure is performed by qualified professionals, but certification isn't a prerequisite for the procedure to be scheduled.
Choice D rationale
Ultrasound to check the umbilical cord's position isn't a standard pre-amniotomy criterion. While it can be useful, the primary concern is the fetal head engagement and cervical readiness.