A postpartum client on magnesium sulfate for preeclampsia suddenly developed severe headaches, floating spots in the field of vision, and right upper quadrant abdominal pain.
Vital signs are BP= 164/100, HR= 96, RR= 16. Laboratory results show liver enzymes are AST = 890, ALT= 980, and platelets = 25,000.This client most likely developed which condition?
HELLP Syndrome.
Postpartum hypertension.
Hypertension in pregnancy.
Superimposed preeclampsia.
The Correct Answer is A
Choice A rationale
The client’s symptoms and lab results are consistent with HELLP Syndrome, a severe form of preeclampsia. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. The client’s elevated liver enzymes and low platelets, along with the reported symptoms, are indicative of this condition.
Choice B rationale
While the client’s high blood pressure could suggest Postpartum hypertension, the presence of severe headaches, visual disturbances, right upper quadrant pain, and abnormal lab results point more towards HELLP Syndrome.
Choice C rationale
Hypertension in pregnancy could be a possibility, but it does not explain all of the client’s symptoms and lab results, particularly the elevated liver enzymes and low platelets.
Choice D rationale
Superimposed preeclampsia is a condition where a pregnant woman with chronic hypertension develops preeclampsia. However, the client’s severe symptoms and lab results are more indicative of HELLP Syndrome.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Vaginal discharge, or leukorrhea, often increases during pregnancy due to higher levels of estrogen and greater blood flow to the vaginal area. It does not typically decrease before labor.
Choice B rationale
Weight gain is expected during pregnancy, but a sudden gain of 0.5 to 1.3 kg is not a typical sign that labor is about to start.
Choice C rationale
Urinary retention is not a typical sign that labor is about to start. In fact, many women find that they need to urinate more frequently as labor approaches, due to increased pressure on the bladder.
Choice D rationale
A surge of energy, often called “nesting,” can be a sign that labor is about to start. Some women experience a burst of energy and the desire to prepare their home for the baby in the days or hours before labor begins.
Correct Answer is A
Explanation
Choice A rationale
Assessing the fetal heart rate pattern is the priority nursing action following an amniotomy. This allows the nurse to monitor for signs of fetal distress, which can occur if the umbilical cord becomes compressed or prolapses as a result of the procedure.
Choice B rationale
Observing the color and consistency of the fluid can provide information about the well-being of the fetus, but it is not the priority action following an amniotomy.
Choice C rationale
Assessing the client’s temperature is important to monitor for signs of infection, but it is not the priority action following an amniotomy.
Choice D rationale
Evaluating the client for the presence of chills and increased uterine tenderness using palpation can help identify complications such as infection or uterine rupture, but it is not the priority action following an amniotomy.
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