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A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin.

The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds.

The fetal heart rate is 160 beats/minute with late decelerations.

What is the priority nursing action?

Increase the rate of oxytocin infusion

Administer oxygen via face mask at 10 L/minute

Turn the client to her left side

Notify the health care provider

Answer and Explanation

The Correct Answer is D

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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Free Nursing Study Resources

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

Explanation

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

• Choice A is correct becausedisseminated 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 becauseacute kidney injuryis 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 becausepulmonary edemais 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 becauseplacental abruptionis 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 becausefetal growth restrictionis 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.

A. Breast engorgement B. Lochia rubra for 3 days postpartum C. Headache unrelieved by analgesics D. Perineal discomfort

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.

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A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin. The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds. The fetal heart rate is 160 beats/minute with late decelerations. What is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

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.)

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

Explanation

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

(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 teaching a client who is at risk for developing preeclampsia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has severe pre-eclampsia and is receiving hydralazine IV. Which of the following adverse effects should the nurse monitor for?

A nurse is caring for a client with severe pre-eclampsia who is being induced with oxytocin. The nurse notes that the client’s contractions are occurring every 2 minutes and lasting 90 seconds. The fetal heart rate is 160 beats/minute with late decelerations. What is the priority nursing action?

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 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 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 teaching to a client who had pre-eclampsia and delivered a healthy newborn. Which of the following statements by the client indicates an understanding of the teaching?