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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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

While infection prevention is vital, ensuring breathing function is more critical after ASP.

Choice B rationale

ASP affects the respiratory system severely; thus, restoring normal breathing is a primary goal.

Choice C rationale

Gastrointestinal function is less immediately affected by ASP compared to respiratory issues.

Choice D rationale

Voiding without pain is important, but respiratory stability takes precedence.

Correct Answer is D

Explanation

Choice A rationale

Reflexes of 3+ indicate hyperreflexia, common in pre-eclampsia, but not necessarily critical. Monitoring is essential but not an emergency.

Choice B rationale

Urinary output of 30 mL/hr is within the acceptable range but requires monitoring for any changes. It's not a critical alert.

Choice C rationale

A respiratory rate of 16 rpm is normal and does not indicate immediate risk requiring physician notification.

Choice D rationale

Serum magnesium level of 10 mg/dL is significantly high, indicating potential toxicity. Immediate physician notification is critical to adjust magnesium sulfate administration.

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