A nurse is caring for a client who has a pressure injury on the coccyx. Which of the following findings should indicate to the nurse that the wound is a stage III pressure injury?

Rationale for correct choices

• Blood pressure: The client’s blood pressure readings are consistently elevated (162/112 mm Hg and 166/110 mm Hg), which is a hallmark of preeclampsia. Hypertension arises from abnormal placental development leading to systemic vasoconstriction. Elevated blood pressure is a primary diagnostic criterion for preeclampsia and is more directly indicative of this condition than HELLP syndrome alone.

• Hemoglobin: The client’s hemoglobin is mildly elevated at 18 g/dL with a hematocrit of 35%, suggesting hemoconcentration and potential microangiopathic hemolysis, a component of HELLP syndrome. While preeclampsia may cause mild hemoconcentration, hemolysis is a defining feature of HELLP. This reflects red blood cell destruction associated with this syndrome.

• Alanine aminotransferase (ALT): ALT is slightly elevated at 40 units/L, reflecting liver involvement. Liver enzyme elevation can occur in severe preeclampsia due to hepatic ischemia and in HELLP syndrome due to hepatocellular injury from hemolysis and microvascular obstruction. The finding supports involvement in both conditions.

• Platelet count: The platelet count is low at 98,000/mm³, which can result from platelet activation and consumption in both preeclampsia and HELLP syndrome. Thrombocytopenia is a hallmark of HELLP syndrome and may also develop in severe preeclampsia. This finding indicates increased risk for bleeding and warrants prompt intervention and monitoring.

A. Morphine 2 mg IV bolus every 4 hr PRN pain: The prescription clearly indicates the dose, route, frequency, and PRN instructions, making it complete and appropriate for administration.

B. Acetaminophen 1,000 PO three times daily: The prescription is missing the unit of measure (mg, g, etc.), which is essential to ensure safe dosing. Without the unit, there is a risk of overdose or underdose, so the nurse must verify this prescription with the provider before administration.

C. Ibuprofen 800 mg PO every 8 hr: This prescription includes the dose, route, and frequency, making it complete. While monitoring for side effects is important, there is no issue requiring verification.

D. Ceftriaxone 250 mg IM x1 dose now: The prescription specifies the dose, route, and single administration, making it clear and safe to administer without additional verification.