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
__
as evidenced by
_
.

Answer and Explanation

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.

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Free Nursing Study Resources

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

Explanation

Choice A rationale: Calcium gluconate is the antidote for magnesium sulfate toxicity, often used in labor inductions complicated by preeclampsia or gestational hypertension. Having it readily available ensures prompt treatment of symptoms like respiratory depression or cardiac arrhythmias caused by magnesium overdose. This safety measure is critical because oxytocin use can increase uterine contractions and magnesium sulfate use requires close monitoring to prevent toxicity.

Choice B rationale: Obtaining the client’s heart rate prior to initiating oxytocin is essential to establish a baseline and monitor for tachycardia or bradycardia, which may affect maternal and fetal safety. Oxytocin can cause cardiovascular changes, including hypertension or arrhythmias, especially in clients with gestational hypertension. Continuous maternal cardiac assessment helps detect adverse effects early and adjust treatment accordingly.

Choice C rationale: Evaluating platelet count before induction is important in clients with gestational hypertension due to the risk of HELLP syndrome, which involves thrombocytopenia. Normal platelet levels range from 150,000 to 400,000/mm³; low levels increase bleeding risk during labor and delivery. Knowing platelet status guides safe management decisions, including anesthesia options and readiness for potential hemorrhagic complications.

Choice D rationale: Assessing for aspirin sensitivity is crucial because aspirin is often used in pregnancy for preeclampsia prevention. Aspirin hypersensitivity can lead to allergic reactions or exacerbation of asthma. Since the client has gestational hypertension, determining aspirin tolerance before administering medications is necessary to prevent adverse drug reactions and ensure safe pharmacologic management.

Choice E rationale: Reviewing the client’s history for heart disease documentation is vital as gestational hypertension increases cardiovascular risk. Preexisting heart conditions can complicate labor induction and oxytocin administration due to possible cardiac overload or arrhythmias. A comprehensive cardiac history ensures appropriate monitoring and interventions to prevent maternal and fetal complications during labor.

A. Assess blood pressure twice daily. B. Administer an IV bolus of lactated Ringer's. C. Assess for edema. D. Obtain a prescription for misoprostol.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a female client, age 34, who is at 38 weeks of gestation to the labor and delivery unit for induction of labor. Which of the following actions should the nurse take prior to implementing the provider’s prescriptions?

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

Explanation

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is obtaining a medical history from a client who is requesting a copper intrauterine device (IUD). The nurse should identify that which of the following conditions is a contraindication for the use of a copper IUD?

A nurse is providing instruction to a client about diagnostic tests during their first prenatal visit at 12 weeks of gestation. Which of the following diagnostic tests should the nurse include in the teaching?

A nurse is performing a nonstress test for a client who is at 38 weeks of gestation. The fetal monitor tracing reveals a series of late decelerations. Which of the following interventions should the nurse implement first?

A nurse is caring for a female client, age 30, at 37 weeks of gestation in the labor and delivery unit for blood pressure observation. After reviewing the client’s electronic health record, the nurse should identify that the client is at risk for developing which of the following complications?

A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccines?

A nurse is reviewing a client's rubella titer of 1:8 at her second prenatal visit. Which of the following statements by the nurse is appropriate?

A nurse is caring for a client who is experiencing severe pain during active labor. Which of the following medications should the nurse plan to administer and document in the client's medical record?