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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

Decreased muscle tone is not typically associated with NAS. NAS often presents with increased muscle tone due to withdrawal symptoms.

Choice B rationale

A continuous high-pitched cry is a hallmark sign of NAS, indicating withdrawal and discomfort. This is due to overstimulation of the central nervous system.

Choice C rationale

Newborns with NAS often have difficulty sleeping due to irritability and discomfort, sleeping for shorter periods.

Choice D rationale

Tremors in NAS are typically pronounced and continuous, not just when disturbed. These tremors result from withdrawal effects on the nervous system.

Correct Answer is B

Explanation

Choice A rationale

Decreased muscle tone is not typically associated with neonatal abstinence syndrome (NAS). Instead, NAS often presents with hypertonia or increased muscle tone due to

withdrawal symptoms.

Choice B rationale

A continuous high-pitched cry is a hallmark sign of NAS, indicating the newborn is experiencing withdrawal and discomfort. This symptom results from the overstimulation of the

central nervous system.

Choice C rationale

Newborns with NAS often have difficulty sleeping and may sleep for shorter periods due to irritability and discomfort. Prolonged sleep after feeding is not characteristic of NAS.

Choice D rationale

Tremors in newborns with NAS are usually pronounced and continuous, not just when disturbed. These tremors are a result of withdrawal effects on the nervous system.

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