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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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Correct Answer is C

Explanation

Choice A rationale

Decreased pain level can be an effect of addressing the cause of pain, but it doesn't indicate improved uterine tone or resolution of atony.

Choice B rationale

Stable blood pressure is important, but it is not the direct outcome of improved uterine tone or the resolution of uterine atony.

Choice C rationale

A firm fundus at or below the umbilicus indicates successful contraction of the uterus, resolving uterine atony and reducing bleeding.

Choice D rationale

Reduced lochial flow can indicate decreased bleeding, but it does not directly indicate improved uterine tone or resolution of uterine atony.

Correct Answer is D

Explanation

Choice A rationale

Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.

Choice B rationale

Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.

Choice C rationale

Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.

Choice D rationale

Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.

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