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
Oral rehydration therapy is not used in place of feedings for infants undergoing phototherapy for elevated bilirubin levels. It's crucial to maintain proper nutrition and hydration through regular feedings.
Choice B rationale
Rotating the baby helps ensure even exposure to the bili lights, which aids in breaking down bilirubin effectively across the baby's body.
Choice C rationale
Applying restraints is inappropriate and unnecessary. It could cause distress and is not a standard practice for phototherapy.
Choice D rationale
Administering intravenous fluids is not typically needed unless there's a risk of dehydration or other medical indications as per the doctor's orders.
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.