A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

disseminated intravascular coagulation (DIC)

elevated platelet count

elevated liver enzymes

hyperglycemia

Answer and Explanation

The Correct Answer is C

A. Disseminated intravascular coagulation (DIC):

DIC is a serious condition characterized by abnormal clotting throughout the body's blood vessels, leading to both bleeding and clotting simultaneously. While it can occur in severe cases of HELLP syndrome, it is not a specific finding used to diagnose HELLP syndrome. Instead, it's a complication that can develop due to various underlying conditions, including HELLP syndrome.

B. Elevated platelet count:

In HELLP syndrome, platelet count is typically decreased, not elevated. HELLP syndrome stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. The low platelet count is a key diagnostic feature of HELLP syndrome and contributes to the risk of bleeding complications.

C. Elevated liver enzymes:

Elevated liver enzymes, particularly elevated levels of AST (aspartate aminotransferase) and ALT (alanine aminotransferase), are hallmark features of HELLP syndrome. Liver involvement is a significant component of this syndrome, and elevated liver enzymes are part of the diagnostic criteria.

D. Hyperglycemia:

While hyperglycemia can occur in various conditions, it is not a characteristic finding of HELLP syndrome. HELLP syndrome primarily affects the liver, blood clotting factors, and platelets, leading to features such as elevated liver enzymes, low platelet count, and hemolysis (destruction of red blood cells).

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Correct Answer is B

Explanation

A. 24 hours before birth and 24 hours after birth:

This option suggests administering Rho(D) immune globulin (RhIg) both before and after birth. However, the standard recommendation is to administer RhIg at 28 weeks' gestation and again within 72 hours after birth. Administering RhIg before birth in this manner is not a standard practice for preventing Rh isoimmunization.

B. At 28 weeks' gestation and again within 72 hours after birth:

This is the correct choice. Administering RhIg at 28 weeks' gestation helps prevent sensitization of the Rh-negative mother to Rh-positive fetal blood cells that may have entered her circulation during pregnancy. Administering it again within 72 hours after birth helps prevent sensitization from any Rh-positive fetal blood cells that may have entered the mother's circulation during delivery.

C. At 32 weeks' gestation and immediately before discharge:

Administering RhIg at 32 weeks' gestation is not the standard recommendation. The standard timing is at 28 weeks' gestation to cover the critical period of sensitization during pregnancy. Administering it immediately before discharge may not provide adequate protection if sensitization has already occurred during pregnancy.

D. In the first trimester and within 2 hours of birth:

Administering RhIg in the first trimester is not a routine practice unless there is a specific indication, such as miscarriage or invasive procedures that may lead to fetal-maternal hemorrhage. Administering it within 2 hours of birth alone does not provide adequate protection against sensitization during pregnancy. The standard recommendation is to administer RhIg at 28 weeks' gestation and again within 72 hours after birth to cover the critical periods of sensitization during pregnancy and delivery.

A. encouraging range-of-motion exercises B. ambulating the client C. applying elasticized stockings D. massaging the client's legs

Correct Answer is C

Explanation

A. Encouraging range-of-motion exercises: Range-of-motion exercises are generally encouraged post-hysterectomy to prevent complications such as blood clots and promote circulation. This action is appropriate and not contraindicated.

B. Ambulating the client: Ambulation is an essential aspect of postoperative care to prevent complications like atelectasis, pneumonia, and deep vein thrombosis (DVT). This action helps improve circulation and aids in the recovery process. It is appropriate and not contraindicated.

C. Applying elasticized stockings: Elasticized stockings, also known as compression stockings, are commonly used postoperatively to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs. However, in the case of abdominal hysterectomy, if the incision site is below the level of the stockings, they may impede circulation to the surgical site and hinder wound healing. Therefore, this action may be contraindicated depending on the specific circumstances of the surgery and incision site.

D. Massaging the client's legs: Massaging the client's legs is generally not recommended post-hysterectomy, especially in the immediate postoperative period. Manipulating the legs could potentially disrupt healing tissues, increase the risk of bleeding, or cause discomfort to the client. Therefore, this action may be contraindicated.

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A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?

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