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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The correct answer is choice A, B, C and E.The nurse should monitor for magnesium toxicity by assessing the deep tendon reflexes, respiratory rate, urine output and serum magnesium level of the client who has severe preeclampsia and is receiving magnesium sulfate IV.Magnesium toxicity can cause life-threatening complications such as hypotension, areflexia (loss of DTRs), respiratory depression, respiratory arrest, oliguria, shortness of breath, chest pains, slurred speech and cardiac arrest.The nurse should also have calcium chloride ready as an antidote for magnesium toxicity.
Choice D is wrong because fetal heart rate is not a direct indicator of magnesium toxicity.However, the nurse should still monitor the fetal heart rate and uterine activity per the Electronic Fetal Monitoring (EFM) Guideline.
Normal ranges for the assessments are:
• Deep tendon reflexes: 1+ to 4+ (normal to hyperactive)
• Respiratory rate: 12 to 20 breaths per minute
• Urine output: at least 30 mL per hour
• Serum magnesium level: 4 to 7 mg/dL (therapeutic range for preeclampsia)
Correct Answer is A
Explanation
Hydralazine can causetachycardia(fast heart rate) as a common side effect.
This is because hydralazine lowers blood pressure by relaxing blood vessels, which can make the heart beat faster to compensate.
Choice B is wrong because hydralazine does not causehyperglycemia(high blood sugar).
Hydralazine is not known to affect glucose metabolism or insulin secretion.
Choice C is wrong because hydralazine does not causehypokalemia(low potassium levels).
Hydralazine is not a diuretic and does not increase potassium excretion.
Choice D is wrong because hydralazine does not causeconstipation.Hydralazine can causediarrheaas a common side effect, but not constipation.
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