A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation and has preeclampsia. The nurse should identify that which of the following findings is indicated with HELLP syndrome?
Bilirubin 1 mg/dL (0.1 to 1 mg/dL)
Uric acid 6.8 mg/dL (2 to 6.6 mg/dL)
Fibrinogen 500 mg/dL (200 to 400 mg/dL)
Aspartate aminotransferase 80 units/L (4 to 20 units/L)
The Correct Answer is D
A. Bilirubin 1 mg/dL (0.1 to 1 mg/dL):
Bilirubin levels can be elevated in conditions involving liver dysfunction or hemolysis, such as HELLP syndrome. However, a bilirubin level of 1 mg/dL falls within the normal range (0.1 to 1 mg/dL). While bilirubin levels may be elevated in some cases of HELLP syndrome, this particular value is not indicative of HELLP syndrome.
B. Uric acid 6.8 mg/dL (2 to 6.6 mg/dL):
Elevated uric acid levels are commonly seen in preeclampsia, but they are not specific to HELLP syndrome. Uric acid levels can rise due to decreased renal function and increased cell breakdown. However, while a level of 6.8 mg/dL is slightly elevated compared to the normal range (2 to 6.6 mg/dL), it alone does not confirm the presence of HELLP syndrome.
C. Fibrinogen 500 mg/dL (200 to 400 mg/dL):
Fibrinogen levels are typically increased in pregnancy, but they can be decreased in conditions associated with consumption coagulopathy, such as disseminated intravascular coagulation (DIC). However, elevated fibrinogen levels are not typically associated with HELLP syndrome. A level of 500 mg/dL is above the normal range (200 to 400 mg/dL), but this finding alone does not indicate HELLP syndrome.
D. Aspartate aminotransferase (AST) 80 units/L (4 to 20 units/L):
Aspartate aminotransferase (AST) is a liver enzyme that can be elevated in liver injury or dysfunction, which can occur in HELLP syndrome. An AST level of 80 units/L is significantly elevated compared to the normal range (4 to 20 units/L), suggesting liver dysfunction. Elevated liver enzymes are a characteristic feature of HELLP syndrome, making this finding the most indicative of HELLP syndrome among the options provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assess for edema:
Assessing for edema is important in monitoring the client's condition as edema can be a sign of worsening preeclampsia. However, it is not an action that requires immediate intervention in the first hour postpartum.
B. Administer an IV bolus of lactated Ringer's:
Administering an IV bolus of lactated Ringer's is not typically indicated for a client with preeclampsia without severe features unless there is evidence of dehydration or hypovolemia. Intravenous fluids may be administered judiciously based on the client's clinical status and fluid balance.
C. Restrict daily oral fluid intake:
Restricting daily oral fluid intake is not recommended for a client in the immediate postpartum period, especially without severe features of preeclampsia. Adequate hydration is important for postpartum recovery and breastfeeding.
D. Obtain a prescription for misoprostol:
Misoprostol is a medication used for various purposes in obstetrics, including the prevention and treatment of postpartum hemorrhage. However, it is not specifically indicated for the management of preeclampsia without severe features. The priority in this situation is close monitoring and supportive care rather than medication administration.
Correct Answer is C
Explanation
A. Place a cool cloth at the site for 15 min before the procedure:
Placing a cool cloth at the site before the procedure is not typically done for a heel stick in newborns. In fact, applying cold to the site can cause vasoconstriction, which may make it more difficult to obtain an adequate blood sample. Additionally, cooling the area can potentially lead to discomfort for the newborn. Therefore, this action is not recommended and would not be appropriate in this scenario.
B. Apply an alcohol pad to the site after the procedure:
While alcohol pads are commonly used for disinfection before certain procedures, they are not typically used after a heel stick to obtain a blood sample for a total serum bilirubin test. Alcohol can interfere with bilirubin testing by altering the bilirubin levels in the blood, leading to inaccurate results. Therefore, applying an alcohol pad after the procedure is not recommended, particularly for bilirubin testing.
C. Puncture the lateral side of the heel for the procedure:
When performing a heel stick on a newborn, it is important to choose the appropriate site for puncture. The lateral side of the heel is preferred over the medial side because it has fewer nerves and blood vessels, reducing the risk of complications and discomfort for the newborn. Puncturing the lateral side also allows for a more controlled and successful blood draw. Therefore, this choice is the most appropriate for obtaining a blood sample for a total serum bilirubin test.
D. Select a 21-gauge needle to perform the procedure:
The choice of needle gauge for a heel stick in a newborn depends on various factors, including the size of the newborn's heel and the desired blood flow rate. However, a 21-gauge needle is relatively large and may cause more pain and tissue trauma compared to smaller gauge needles, especially in newborns. Smaller gauge needles, such as 23 or 25 gauge, are typically preferred for heel sticks in newborns to minimize discomfort and trauma to the tissue. Therefore, selecting a 21-gauge needle may not be the most appropriate choice for this procedure.
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