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. .
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
Choice A rationale
Induction timing is secondary to assessing readiness. The Bishop score determines cervical favorability for induction success.
Choice B rationale
The Bishop score assesses cervical readiness for labor induction, which is vital in planning an effective induction.
Choice C rationale
Refusal to induce without considering clinical data is inappropriate. The Bishop score evaluation determines readiness.
Choice D rationale
Prostaglandin preparation follows Bishop score assessment to ensure induction safety and efficacy.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Pumping up the vacuum manually to the pressure indicated on the pump is a standard procedure but doesn't directly minimize liability.
Choice B rationale
Recognizing cup detachment (pop off) as a warning sign is critical, as it indicates excessive force or poor positioning, which can lead to fetal or maternal injury.
Choice C rationale
Limiting the cup's attachment to the fetal head to 5 to 10 minutes reduces the risk of scalp injury and other complications, thus minimizing liability.
Choice D rationale
Timing the procedure from insertion of the cup into the vagina until the birth is a guideline but doesn't specifically address liability concerns.
Choice E rationale
Releasing pressure between contractions prevents continuous suction on the fetal head, reducing the risk of injury and thereby minimizing liability.