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
Explanation
Absence of seizures indicates a therapeutic response to magnesium sulfate therapy for a client with eclampsia.Magnesium sulfate is used to prevent seizures in women with preeclampsia, a complication of pregnancy characterized by high blood pressure and organ dysfunction.Magnesium sulfate may act as a vasodilator, an anticonvulsant, and a protector of the blood-brain barrier.
Choice B is wrong because a decrease in urine output may indicate renal impairment, which is a complication of preeclampsia and eclampsia.
Choice C is wrong because an increase in deep tendon reflexes may indicate hyperreflexia, which is a sign of increased neuromuscular irritability and a risk factor for seizures.
Choice D is wrong because an increase in respiratory rate may indicate respiratory distress, which can be caused by pulmonary edema, another complication of preeclampsia and eclampsia.
Normal ranges for urine output are 0.5 to 1 mL/kg/hour, for deep tendon reflexes are 1+ to 2+, and for respiratory rate are 12 to 20 breaths per minute.
Correct Answer is A
Explanation
Stop the magnesium sulfate infusion.
The client is showing signs of magnesium toxicity, such as absent deep tendon reflexes, which can lead to respiratory depression and cardiac arrest.
Magnesium sulfate is an anticonvulsant that is used to prevent seizures in eclampsia, but it can also cause vasodilation and hypotension.
The nurse should stop the infusion and monitor the client’s vital signs and neurological status.
Choice B. Increase the rate of the hydralazine infusion is wrong because hydralazine is an antihypertensive that lowers blood pressure.
The client’s blood pressure is already within the normal range for eclampsia (140/90 to 160/110 mmHg), so increasing the rate of hydralazine could cause hypotension and compromise placental perfusion.
Choice C. Administer calcium gluconate IV push is wrong because calcium gluconate is an antidote for magnesium toxicity, but it should not be given IV push.
It should be given slowly over 10 to 20 minutes to avoid cardiac arrhythmias and bradycardia.
Choice D. Prepare for immediate delivery of the fetus is wrong because delivery of the fetus is not indicated at this time.
The client’s vital signs are stable and there is no evidence of fetal distress or placental abruption.
Delivery of the fetus is the definitive treatment for eclampsia, but it should be done when the maternal and fetal conditions are optimal.
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