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
Induction timing is secondary to assessing readiness. The Bishop score determines cervical favorability for induction success.
Choice B rationale
The Bishop score assesses cervical readiness for labor induction, which is vital in planning an effective induction.
Choice C rationale
Refusal to induce without considering clinical data is inappropriate. The Bishop score evaluation determines readiness.
Choice D rationale
Prostaglandin preparation follows Bishop score assessment to ensure induction safety and efficacy.
Correct Answer is D
Explanation
Choice A rationale
A low transverse uterine scar is considered the safest type of uterine incision for a VBAC because it is less likely to rupture compared to other types of scars. Therefore, a low transverse uterine scar would not disqualify the patient for VBAC.
Choice B rationale
Patient asking multiple questions does not disqualify her for VBAC. Patient education and ensuring the patient’s understanding and agreement with the procedure is an essential part of the process.
Choice C rationale
Induction of labor in the first pregnancy does not automatically disqualify a patient from attempting VBAC. The success of VBAC depends on multiple factors including the reason for the initial cesarean section.
Choice D rationale
A cesarean due to pelvic abnormalities would disqualify the patient for VBAC because the underlying pelvic condition that necessitated the initial cesarean section is likely still present and would increase the risk of complications during vaginal birth.