A nurse is reviewing the electronic medical record of a female client, age 31, at 36 weeks of gestation in the antepartum unit.
Complete the following sentence by using the lists of options.
After reviewing the information in the client’s EMR, the nurse determines that the client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
The client is at risk for developing HELLP syndrome as evidenced by Liver enzymes.
Rationale for correct answers:
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe form of preeclampsia often presenting in the third trimester. This client has thrombocytopenia (platelets 100,000/mm³; normal 150,000–400,000/mm³), elevated blood urea nitrogen (25 mg/dL; normal 10–20 mg/dL), borderline elevated creatinine (1.1 mg/dL; normal 0.5–1.0 mg/dL), and elevated uric acid (9.8 mg/dL; normal 2.7–7.3 mg/dL), which suggests possible renal impairment and oxidative stress typical in HELLP. Mild epigastric discomfort also aligns with liver involvement. Although liver enzymes are not listed in the labs here, the question implies liver enzyme elevation as a hallmark finding to confirm HELLP, which is essential to monitor. Hemolysis would typically manifest as anemia, but hemoglobin and hematocrit are near normal. Prompt recognition and further testing of liver enzymes (AST, ALT) are critical for diagnosis and management.
Rationale for incorrect Response 1 options:
Chorioamnionitis is an infection of the amniotic sac, usually presenting with fever, uterine tenderness, and elevated WBC, which are not present here. Gestational diabetes is characterized by hyperglycemia, but the client’s blood glucose is only mildly elevated and not diagnostic. Pyelonephritis involves urinary tract infection with systemic symptoms like fever and flank pain, absent in this case.
Rationale for incorrect Response 2 options:
Amniotic membrane status is unrelated here, as there is no rupture or infection evidence. Ketonuria reflects starvation or diabetes, which is not indicated. Blood glucose is only mildly elevated and insufficient to diagnose gestational diabetes or explain current symptoms.
Take home points:
- HELLP syndrome involves low platelets, elevated liver enzymes, and hemolysis, often with epigastric pain.
- Early lab monitoring including liver enzymes is vital for timely diagnosis.
- Elevated BUN, creatinine, and uric acid can signal renal impairment in HELLP.
- Differentiate HELLP from infections or gestational diabetes by clinical presentation and specific labs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Assessing blood pressure twice daily is insufficient for a client with preeclampsia postpartum. Preeclampsia can worsen or manifest postpartum, necessitating more frequent monitoring, typically every 4 hours or more depending on the severity, to detect changes indicating progression or resolution of the condition and guide timely intervention.
Choice B rationale
Administering an IV bolus of lactated Ringer's could exacerbate fluid overload in a client with preeclampsia, as these clients often have compromised renal function and increased extracellular fluid. Fluid administration should be carefully managed to avoid pulmonary edema, and boluses are generally avoided unless hypovolemia is clearly indicated.
Choice C rationale
Assessing for edema is crucial postpartum for a client with preeclampsia. Preeclampsia is characterized by widespread endothelial dysfunction, leading to increased vascular permeability and fluid shifts into interstitial spaces. Monitoring edema, particularly in the face and extremities, helps evaluate fluid status and assess the resolution or persistence of the preeclamptic state.
Choice D rationale
Obtaining a prescription for misoprostol is not indicated for the management of preeclampsia without severe features postpartum. Misoprostol is a prostaglandin analog primarily used for cervical ripening, labor induction, or postpartum hemorrhage management due to its uterotonic properties, not for the direct management of hypertension or other preeclamptic symptoms.
Correct Answer is D
Explanation
A. The bladder is distended upon palpation: A distended bladder suggests urinary retention, not effective voiding. This may impair uterine contraction and increase the risk of hemorrhage.
B. The uterine fundus is 2 cm above the umbilicus: A high-rising fundus may indicate a full bladder that is displacing the uterus, often due to incomplete voiding.
C. The client does not feel the urge to urinate: Lack of urge may indicate altered bladder sensation, a potential complication after catheter removal and childbirth.
D. The client urinates 30 mL/hr: Urine output of ≥30 mL/hr is considered adequate and reflects effective voiding and kidney function, especially in the postpartum period.
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