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 C
Explanation
Choice A rationale
Prolonged labor is not directly linked to drug use and does not present as an immediate complication.
Choice B rationale
Prolapsed cord is not associated with substance abuse and lacks direct connection to this scenario.
Choice C rationale
Cocaine use heightens the risk of abruptio placentae, a serious condition where the placenta detaches prematurely.
Choice D rationale
Retained placenta is a concern but less likely than abruptio placentae in the context of cocaine use.
Correct Answer is D
Explanation
Choice A rationale
Checking blood sugar is important in gestational diabetes but isn't immediate priority in a triage setting compared to assessing urgent conditions that could harm the fetus or mother immediately.
Choice B rationale
Assessing vaginal blood loss post-abortion is crucial, but in the presence of ruptured membranes, fetal heart rate checks take precedence to ensure the fetus's immediate well-being.
Choice C rationale
Assessing patellar reflexes in pre-eclampsia management is significant, but immediate priority in labor and delivery triage goes to ensuring fetal safety after membrane rupture.
Choice D rationale
Checking the fetal heart rate after membrane rupture is a priority because it provides immediate information about the fetus's status and any potential complications like cord prolapse or distress.