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 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.

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 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 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?

Correct Answer is C

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 evaluating the fetal status of a client who has preeclampsia and is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider as a sign of fetal compromise?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 34 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

A nurse is reviewing the electronic health record of a client who has severe preeclampsia and is being induced with oxytocin. Which of the following findings should the nurse report to the provider immediately?

A nurse is providing discharge instructions to a client who had severe pre-eclampsia and delivered a healthy baby at 36 weeks of gestation. The nurse should instruct the client to report which symptom to the provider as a possible sign of postpartum pre-eclampsia?

A nurse is caring for a client with eclampsia who is having a tonic-clonic seizure. Which action should the nurse take first?

A nurse is reviewing the laboratory results of a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously. Which of the following results should the nurse notify the provider about? (Select all that apply.)

A nurse is assessing a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should alert the nurse to suspect magnesium toxicity?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with eclampsia. What clinical indicator would suggest that the therapy is successful?

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.