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)

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Perform fetal scalp stimulation:

Fetal scalp stimulation involves applying pressure to the fetal scalp during a vaginal examination to elicit a response from the fetus, such as an acceleration of the fetal heart rate. While this can provide additional information about fetal well-being, it is not the initial priority when late decelerations are observed on the fetal monitor. The focus should first be on interventions aimed at improving fetal oxygenation to address the underlying cause of the late decelerations.

B. Administer oxygen via a face mask:

Administering oxygen to the mother is a priority intervention when late decelerations of the fetal heart rate are observed on the external fetal monitor. Late decelerations often indicate uteroplacental insufficiency, where the fetus is not receiving adequate oxygenation. Administering oxygen to the mother helps increase oxygen levels in her blood, improving oxygen delivery to the fetus and potentially mitigating the effects of uteroplacental insufficiency.

C. Elevate the client's head:

Elevating the client's head is not indicated when late decelerations are observed. This position could potentially compromise maternal-fetal circulation by reducing blood flow to the placenta. Maintaining a side-lying or semi-Fowler's position is often recommended to improve blood flow to the placenta and enhance fetal oxygenation.

D. Decrease the rate of IV fluids:

Adjusting the rate of IV fluids may be considered in some situations, such as if there is evidence of fluid overload or if the mother is receiving excessive amounts of IV fluids. However, it is not typically the initial intervention for addressing late decelerations. The focus should first be on interventions aimed at improving maternal-fetal oxygenation, such as administering oxygen and positioning the client appropriately.

A. Place a cool cloth at the site for 15 min before the procedure. B. Apply an alcohol pad to the site after the procedure. C. Puncture the lateral side of the heel for the procedure. D. Select a 21-gauge needle to perform the procedure.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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