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?

Breast engorgement

Lochia rubra for 3 days postpartum

Headache unrelieved by analgesics

Perineal discomfort

Answer and Explanation

The Correct Answer is C

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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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. Respiratory rate of 10 breaths/min B. Deep tendon reflexes of 2+ C. Urine output of 40 mL/hour D. Serum magnesium level of 6 mq/L

Correct Answer is A

Explanation

Respiratory rate of 10 breaths/min.

This is a sign ofmagnesium toxicity, which can occur when a client receives magnesium sulfate infusion for severe pre-eclampsia.Magnesium toxicity can causemuscle weakness,difficulty breathing,irregular heartbeats, andcardiac arrest.

Choice B is wrong because deep tendon reflexes of 2+ are normal and do not indicate magnesium toxicity.

Choice C is wrong because urine output of 40 mL/hour is adequate and does not indicate magnesium toxicity.

The minimum urine output for an adult is 30 mL/hour.

Choice D is wrong because serum magnesium level of 6 mEq/L is within the normal range of 1.7 to 2.3 mEq/L and does not indicate magnesium toxicity.Magnesium levels above 2.6 mEq/L can indicate hypermagnesemia.

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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?

Nursing Test Bank

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

Correct Answer is A

Explanation

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 administering magnesium sulfate IV to a client who has severe preeclampsia. Which of the following assessments should the nurse perform to monitor for magnesium toxicity? Select all that apply.

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 educating a client with severe pre-eclampsia who is receiving magnesium sulfate intravenously about the possible side effects of the medication. Which of the following statements should the nurse include in the teaching?

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?

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).

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse identify as an indication of magnesium sulfate toxicity?

A nurse is evaluating the effectiveness of magnesium sulfate therapy for a client with pre-eclampsia. Which outcome would indicate that the therapy is successful?

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?