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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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.