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.

Monitor vital signs and urine output

Administer corticosteroids as prescribed

Check for signs of fluid overload or transfusion reaction

Encourage oral intake of fluids and electrolytes

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

Explanation

The correct answer is choices B, C, D, and E.These are all risk factors for pre-eclampsia according to various sources.

Choice A is wrong because age over 35 years is not a risk factor for pre-eclampsia by itself, although it may be associated with other conditions that increase the risk, such as chronic hypertension or diabetes.

Pre-eclampsia is a complication of pregnancy that involves high blood pressure, protein in the urine, and organ damage.It can affect both the mother and the fetus and can lead to serious complications such as eclampsia (seizures), placental abruption, and stillbirth.It is more common in first pregnancies, especially with a new partner, because of the immune response to the foreign fetal antigens.Obesity, diabetes mellitus, and multiple gestation are also risk factors because they increase the metabolic and vascular demands on the placenta and the mother.

Normal ranges for blood pressure and proteinuria in pregnancy are:

• Blood pressure: less than 140/90 mmHg

• Proteinuria: less than 300 mg/24 hours or less than 30 mg/dL on a random urine sample

A. “You can stop taking your blood pressure medication now that you have delivered your baby.” B. “You should avoid breastfeeding your baby until your blood pressure is normal.” C. “You should report any headache or visual changes to your doctor immediately.” D. “You should limit your fluid intake to prevent fluid overload.”

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.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a pregnant client about the risk factors for pre-eclampsia. Which of the following should the nurse include? (Select all that apply).

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

Explanation

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

(select all that apply) A nurse is reviewing the laboratory results of a client with eclampsia who is receiving magnesium sulfate. Which of the following values should the nurse report to the provider? (Select all that apply.)

A nurse is providing discharge teaching to a client who had HELLP syndrome and a cesarean birth. The nurse should instruct the client to report which of the following findings to the provider?

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

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. Which of the following findings indicates a therapeutic response?

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 monitoring a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following assessments is the most important for the nurse to perform?

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 HELLP syndrome who is receiving a blood transfusion.

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