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 D
Explanation
Choice A rationale
Reduction of fever is not a primary effect of carboprost tromethamine. This medication is primarily used to induce uterine contractions to manage postpartum hemorrhage.
Choice B rationale
While maintaining stable blood pressure is important, it is not the specific indicator of carboprost tromethamine's effectiveness. This medication is used to control bleeding.
Choice C rationale
Increased comfort, although significant, is not the direct effect of carboprost tromethamine. The primary aim is to induce uterine contractions to manage hemorrhage.
Choice D rationale
Decreased lochia rubra indicates the reduction of postpartum bleeding, which is the primary purpose of administering carboprost tromethamine. This outcome shows the medication is effective.
Correct Answer is C
Explanation
Choice A rationale
Extension of the episiotomy is not a guideline for vacuum-assisted delivery. Episiotomy extension is considered based on perineal conditions during delivery, not as a primary
guideline for vacuum procedures.
Choice B rationale
Signs of fetal compromise resolving is critical for fetal safety but isn't specific to the guidelines for a vacuum-assisted delivery. Continuous fetal monitoring assesses for compromise,
not just vacuum application.
Choice C rationale
The "three-pull" rule refers to the number of attempts allowed with the vacuum to avoid excessive force and trauma. This guideline ensures safety during the procedure, preventing
overuse of vacuum pressure.
Choice D rationale
Full anesthesia status is unrelated to the guidelines for vacuum-assisted delivery. Anesthesia choices depend on patient and procedural needs, but aren't a guideline criterion for
vacuum use.