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A nurse is caring for a client with HELLP syndrome who is receiving a blood transfusion.

What nursing interventions are appropriate for this client? Select all that apply.

A.

Monitor vital signs and urine output

B.

Administer corticosteroids as prescribed

C.

Check for signs of fluid overload or transfusion reaction

D.

Encourage oral intake of fluids and electrolytes

E.

Maintain bed rest and a quiet environment

Answer and Explanation

Correct Answer : A,C

The correct answer is choice A and C. A client with HELLP syndrome is at risk for bleeding, liver damage, and fluid overload or transfusion reaction. Therefore, the nurse should monitor vital signs and urine output to assess for signs of shock, hemorrhage, or renal failure. The nurse should also check for signs of fluid overload or transfusion reaction such as dyspnea, crackles, edema, fever, chills, or rash.

Choice B is wrong because corticosteroids are not indicated for clients with HELLP syndrome unless they have severe thrombocytopenia or need to delay delivery for fetal lung maturity. Corticosteroids may worsen the liver function and increase the risk of infection.

Choice D is wrong because encouraging oral intake of fluids and electrolytes may exacerbate fluid overload and hypertension in clients with HELLP syndrome. Fluid restriction and diuretics may be prescribed to reduce the risk of pulmonary edema and cerebral edema.

Choice E is wrong because maintaining bed rest and a quiet environment may not be sufficient to prevent the progression of HELLP syndrome. The definitive treatment for HELLP syndrome is delivery of the fetus and placenta as soon as possible. Bed rest and a quiet environment may help reduce blood pressure and stress, but they are not the main interventions for this condition.


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Related Questions

Correct Answer is C

Explanation

Headache unrelieved by analgesics.This is because headache is a common symptom of HELLP syndrome, a rare pregnancy complication that can cause high blood pressure, seizures, stroke or liver rupture.HELLP syndrome is a type of preeclampsia and has similar symptoms.

Choice A is wrong because breast engorgement is a normal postpartum condition that occurs when the breasts are full of milk and become swollen and tender.

It is not related to HELLP syndrome.

Choice B is wrong because lochia rubra for 3 days postpartum is a normal finding that indicates the shedding of the uterine lining after delivery.

It is not related to HELLP syndrome.

Choice D is wrong because perineal discomfort is a common postpartum discomfort that results from the stretching and tearing of the perineal tissues during vaginal delivery.

It is not related to HELLP syndrome.

Normal ranges for blood pressure are less than 120/80 mmHg, for platelet count are 150,000 to 450,000 per microliter, and for liver enzymes are 7 to 56 units per liter for AST and 0 to 35 units per liter for ALT.

Correct Answer is D

Explanation

The correct answer is d. Notify the health care provider.

Rationale for Choice A:

  • Increasing the rate of oxytocin infusion is contraindicated in this situation.
  • Oxytocin stimulates uterine contractions,and the client is already experiencing excessively frequent and prolonged contractions.
  • Increased oxytocin could further compromise uteroplacental blood flow and exacerbate fetal distress.
  • It could also put the client at higher risk for uterine rupture,a serious complication associated with oxytocin use.

Rationale for Choice B:

  • While administering oxygen is a common intervention for fetal distress,it's not the priority action in this case.
  • Late decelerations in fetal heart rate are typically caused by uteroplacental insufficiency,which means the fetus isn't receiving adequate oxygen and nutrients from the placenta.
  • Oxygen administered to the mother may not significantly improve fetal oxygenation if the underlying issue is impaired placental perfusion.

Rationale for Choice C:

  • Turning the client to her left side is a recommended position to improve placental blood flow.
  • However,in this situation,it's not the priority action given the presence of late decelerations and excessive uterine contractions.
  • It may be a helpful adjunct measure,but it won't address the primary cause of fetal distress.

Rationale for Choice D:

  • Notifying the health care provider is the most crucial action because:
    • The client has severe pre-eclampsia,a serious condition that requires close monitoring and management.
    • The frequent and prolonged contractions,along with late decelerations in the fetal heart rate,indicate potential fetal distress.
    • The health care provider needs to be aware of these changes to make timely decisions regarding interventions,such as:
      • Adjusting the oxytocin infusion
      • Expediting delivery if necessary
      • Implementing other measures to improve fetal well-being
      • Closely monitoring the mother's condition to prevent complications of pre-eclampsia

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