A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.

Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

Blood pressure of 150/90 mm Hg

Urine protein of 2+

Epigastric pain

Facial edema

Answer and Explanation

The Correct Answer is C

This is a manifestation of severe preeclampsia that indicates liver involvement and can precede a seizure.

The nurse should report this finding to the provider immediately and prepare for possible delivery of the baby.

Choice A is wrong because blood pressure of 150/90 mm Hg is a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the systolic pressure is 160 mm Hg or higher or the diastolic pressure is 110 mm Hg or higher.

Choice B is wrong because urine protein of 2+ is also a sign of mild preeclampsia, not severe. Severe preeclampsia is diagnosed when the urine protein is 3+ or higher.

Choice D is wrong because facial edema is a common finding in normal pregnancy and does not indicate severe preeclampsia. Other signs of severe preeclampsia include headache, blurred vision, oliguria, thrombocytopenia, and pulmonary edema.

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Correct Answer is ["A","C","D","E"]

Explanation

The correct answer is choice A, C, D and E. Here is why:

• Choice A is correct becausedisseminated intravascular coagulation (DIC)is a blood clotting disorder that can develop as a complication of HELLP syndrome.DIC can result in excessive bleeding or blood clots in various organs.

• Choice B is wrong becauseacute kidney injuryis not a common complication of HELLP syndrome.However, preeclampsia can cause kidney damage and proteinuria (high levels of protein in the urine).

• Choice C is correct becausepulmonary edemais a condition where fluid accumulates in and around the lungs, impairing oxygen absorption.It can occur as a complication of HELLP syndrome due to high blood pressure and fluid overload.

• Choice D is correct becauseplacental abruptionis a condition where the placenta separates from the uterus before delivery.

It can cause severe bleeding and fetal distress.It can occur as a complication of HELLP syndrome due to high blood pressure and abnormal blood clotting.

• Choice E is correct becausefetal growth restrictionis a condition where the fetus does not grow as expected.It can occur as a complication of HELLP syndrome due to reduced blood flow and oxygen delivery to the placenta.

Normal ranges for liver enzymes are:

• Alanine aminotransferase (ALT): 7 to 55 units per liter (U/L)

• Aspartate aminotransferase (AST): 8 to 48 U/L

• Alkaline phosphatase (ALP): 45 to 115 U/L

Normal range for platelet count is:

• 150,000 to 450,000 platelets per microlitre.

A. The client has no seizures B. The client has a diuresis C. The client has improved fetal movement D. The client has increased platelet count

Correct Answer is A

Explanation

The client has no seizures.Magnesium sulfate therapy is used to prevent seizures in women with preeclampsia and eclampsia.Seizures are a life-threatening complication of eclampsia and indicate a failure of therapy.

Choice B is wrong because diuresis is not a goal of magnesium sulfate therapy.Diuresis may indicate fluid overload or renal impairment, which are complications of preeclampsia and eclampsia.

Choice C is wrong because improved fetal movement is not a direct outcome of magnesium sulfate therapy.Fetal movement may be affected by many factors, such as gestational age, maternal position, and fetal well-being.

Choice D is wrong because increased platelet count is not a result of magnesium sulfate therapy.Platelet count may be decreased in preeclampsia and eclampsia due to disseminated intravascular coagulation, which is a serious complication that requires prompt treatment.

Normal ranges for blood pressure are less than 140/90 mm Hg, for proteinuria are less than 300 mg/24 hours, for platelet count are 150,000 to 400,000/mm3, and for serum magnesium are 1.5 to 2.5 mEq/L.

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A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia. Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a diagnosis of HELLP syndrome. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client who has eclampsia. Which of the following outcomes indicates that the therapy is successful?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 28 weeks of gestation and has a blood pressure of 160/100 mm Hg. The nurse should anticipate a prescription for which of the following medications?

A nurse is caring for a client with eclampsia who is receiving magnesium sulfate and has a magnesium level of 10 mg/dL. Which of the following medications should the nurse have available as an antidote?

A nurse is caring for a client who is receiving magnesium sulfate for severe preeclampsia. Which of the following actions should the nurse take?

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

A nurse is assessing a client with severe pre-eclampsia who is receiving magnesium sulfate infusion. Which finding should alert the nurse to suspect magnesium toxicity?

A nurse is teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning to administer hydralazine to a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following actions should the nurse take before giving the medication? (Select all that apply.)

A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia. Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?

A nurse is assessing a client who is 24 weeks pregnant and has preeclampsia.

Which of the following findings should the nurse report to the provider as a manifestation of severe preeclampsia?