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.)

Disseminated intravascular coagulation (DIC)

Acute kidney injury

Pulmonary edema

Placental abruption

Fetal growth restriction

Answer and Explanation

Correct Answer : A,C,D,E

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

• Choice A is correct because disseminated 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 because acute kidney injury is 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 because pulmonary edema is 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 because placental abruption is 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 because fetal growth restriction is 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.

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Correct Answer is C

Explanation

The nurse should instruct the client to report any headache or visual changes to the doctor immediately, as these are signs of worsening preeclampsia that can lead to serious complications such as stroke, eclampsia, or HELLP syndrome.Preeclampsia can persist or even begin after delivery, most often within 48 hours, so the client should monitor her blood pressure and symptoms until they resolve.

Choice A is wrong because the client should not stop taking her blood pressure medication without consulting her doctor.Blood pressure medication helps lower the blood pressure and protects the organs from damage.The blood pressure usually returns to normal within several days to weeks after delivery, but some clients may need medication for longer.

Choice B is wrong because the client should not avoid breastfeeding her baby unless there is a medical reason to do so.Breastfeeding has many benefits for both the mother and the baby, and does not affect the blood pressure or the preeclampsia.

Choice D is wrong because the client should not limit her fluid intake to prevent fluid overload.Fluid overload is not a common complication of preeclampsia, and limiting fluids can cause dehydration and affect the milk supply for breastfeeding.

The client should drink enough fluids to stay hydrated and follow a balanced diet.

A. Respiratory rate of 10 breaths/min B. Deep tendon reflexes of 2+ C. Urine output of 40 mL/hour D. Serum magnesium level of 6 mq/L

Correct Answer is A

Explanation

Respiratory rate of 10 breaths/min.

This is a sign ofmagnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia.Magnesium toxicity can causemuscle weakness,difficulty breathing,irregular heartbeats, andcardiac arrest.

Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.

Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.

The minimum urine output for an adult is 30 mL/hour.

Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L and does not indicate magnesium toxicity.Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who had preeclampsia and delivered her baby 2 days ago. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

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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.)