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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 A

Explanation

Choice A rationale

Vaginal hematomas are usually associated with severe pain due to the accumulation of blood in the tissues.

Choice B rationale

Bleeding might be visible, but hematomas often cause internal accumulation, not external bleeding.

Choice C rationale

Warmth is not typically associated with hematomas; instead, pain and swelling are more common.

Choice D rationale

Redness may occur, but pain is the most consistent symptom.

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