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.

Answer and Explanation

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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Correct Answer is C

Explanation

Continuous contractions lasting 2 minutes could indicate uterine tetany, which could lead to uterine rupture, a life-threatening situation that requires immediate medical attention.

A. Eagerness to learn newborn care skills. B. Expressions of excitement. C. Focus on the family unit and its members. D. Lack of appetite.

Correct Answer is B

Explanation

The correct answer is choiceB. Expressions of excitement.

Choice A rationale:

Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase, which follows the “taking-in” phase.During the taking-hold phase, the mother becomes more independent and starts to take an active role in caring for her newborn.

Choice B rationale:

Expressions of excitement are typical during the “taking-in” phase. This phase occurs in the first 1-2 days postpartum, where the mother is primarily focused on herself and her birth experience.She may be excited and talkative about the birth process.

Choice C rationale:

Focus on the family unit and its members is more aligned with the “letting-go” phase, which is the final phase of maternal postpartum adjustment.In this phase, the mother starts to integrate the newborn into the family and adjusts to her new role.

Choice D rationale:

Lack of appetite can occur during the “taking-in” phase due to exhaustion and the physical demands of labor, but it is not a defining characteristic of this phase.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor, which of the following assessment findings should the nurse report to the provider first?

Correct Answer is C

Explanation

A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

Correct Answer is B

Explanation

A nurse is admitting a patient who is at 30 weeks of gestation and is in preterm labor.The patient has a new prescription for betamethasone and asks the nurse about the purpose of this medication. Which explanation should the nurse provide?

The nurse is conducting a newborn assessment and identifies a collection of blood beneath the newborn’s scalp that does not cross the suture lines. How should the nurse document this finding?

A nurse is caring for a client who had a vaginal delivery 2 hours ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

Which of the following observations should be recorded as part of a newborn gestational age assessment?

A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, what action should the nurse take?

A nurse is examining a client who is in active labor and observes that the presenting part is in the left occiput posterior position. What is the clinical interpretation of this finding?

A nurse is caring for a client who is 42 weeks of gestation. Exhibits Based on the updated assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse’s planned actions are anticipated, nonessential, or contraindicated.

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply)