The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin (Pitocin) infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransferase (AST) level, and a falling hematocrit. The laboratory results are indicative of which condition?

Disseminated intravascular coagulation (DIC) syndrome

Eclampsia

Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome

Idiopathic thrombocytopenia

Answer and Explanation

The Correct Answer is C

Choice A reason: Disseminated intravascular coagulation (DIC) syndrome is not the correct answer, as it is a coagulation disorder that causes widespread clotting and bleeding in the body. DIC can occur as a complication of severe preeclampsia, but it is not indicated by the laboratory results. DIC would cause a low platelet count, but also a prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT), and a low fibrinogen level.

Choice B reason: Eclampsia is not the correct answer, as it is a seizure disorder that occurs in clients with severe preeclampsia. Eclampsia can occur as a complication of severe preeclampsia, but it is not indicated by the laboratory results. Eclampsia would cause a high blood pressure, but also a proteinuria, edema, and hyperreflexia.

Choice C reason: Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome is the correct answer, as it is a variant of severe preeclampsia that affects the blood and the liver. HELLP syndrome is indicated by the laboratory results, as it causes a low platelet count, an elevated AST level, and a falling hematocrit. HELLP syndrome would also cause a high blood pressure, a proteinuria, and a right upper quadrant pain.

Choice D reason: Idiopathic thrombocytopenia is not the correct answer, as it is an autoimmune disorder that causes the destruction of platelets by antibodies. Idiopathic thrombocytopenia can affect pregnant women, but it is not related to severe preeclampsia or the laboratory results. Idiopathic thrombocytopenia would cause a low platelet count, but not an elevated AST level or a falling hematocrit.

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Correct Answer is A

Explanation

Choice A reason: Respiratory rate is the priority nursing assessment for this client, because magnesium sulfate can cause respiratory depression, which is a life-threatening complication. The nurse should monitor the client's respiratory rate closely, and discontinue the infusion if it falls below 12 breaths per minute.

Choice B reason: Bowel sounds is not a priority nursing assessment for this client, because magnesium sulfate does not have a significant effect on the gastrointestinal system. The nurse should assess the client's bowel sounds as part of the routine physical examination, but it is not a critical parameter for this medication.

Choice C reason: Time of last food intake is not a priority nursing assessment for this client, because magnesium sulfate does not interact with food or affect the absorption of nutrients. The nurse should inquire about the client's dietary intake and preferences, but it is not a vital factor for this medication.

Choice D reason: Temperature is not a priority nursing assessment for this client, because magnesium sulfate does not cause fever or hypothermia. The nurse should measure the client's temperature as part of the vital signs, but it is not a key indicator for this medication.

A. Increased subcutaneous fat B. Dry, cracked skin C. Scant scalp hair D. Copious vernix

Correct Answer is B

Explanation

Choice A reason: Increased subcutaneous fat is not a typical finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have less subcutaneous fat, and may appear thin and wasted.

Choice B reason: Dry, cracked skin is a common finding in a newborn who was born at 42.5 weeks of gestation, because the skin has been exposed to the amniotic fluid for a prolonged period. The skin may also appear peeling, wrinkled, or leathery.

Choice C reason: Scant scalp hair is not a usual finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a preterm newborn. A postterm newborn tends to have more scalp hair, and may also have long nails and abundant lanugo.

Choice D reason: Copious vernix is not a specific finding in a newborn who was born at 42.5 weeks of gestation, because it is more characteristic of a term or preterm newborn. A postterm newborn tends to have little or no vernix, which is a white, cheesy substance that protects the skin in utero.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Correct Answer is A

Explanation

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A nurse is preparing to administer an injection of Rh0 (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications?

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?