The nurse is continuing to assist with the care of the client.

Nurses' Notes.

0900: 0930: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen.

Client also reports urinary frequency and decreased fetal movement.

Client is a. gravida 3, para 2 with one preterm birth.

Client reports a constant and throbbing headache and rates their pain as a 6 on a scale of 0 to 10.

Denies visual disturbances.

+3 pitting edema in bilateral lower extremities.

Patellar reflex 4+ without the presence of clonus.

Client reports occasional nighttime leg cramps.

Reports 3 fetal movements within the last 30 min.

External fetal monitor applied with a. baseline FHR 140/min with occasional accelerations and moderate variability.

No uterine contractions noted.

The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome.

Each finding may support more than one disease process.

Blood pressure

Hemoglobin

Platelet count

Alanine aminotransferase

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Blood pressure: This finding is consistent with preeclampsia, but not HELLP syndrome. Preeclampsia is defined as new-onset hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) after 20 weeks of gestation, with or without proteinuria. HELLP syndrome is a severe form of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelets, but does not necessarily cause hypertension. Hemoglobin: This finding is consistent with HELLP syndrome, but not preeclampsia.

Hemolysis is one of the main features of HELLP syndrome, which causes a decrease in hemoglobin levels. Preeclampsia does not typically affect hemoglobin levels, unless there is significant blood loss or hemodilution.

Platelet count: This finding is consistent with both preeclampsia and HELLP syndrome. Low platelets (thrombocytopenia) are a common complication of preeclampsia, especially in severe cases. They are also a diagnostic criterion for HELLP syndrome, which requires a platelet count of less than 100,000/mm3.

Alanine aminotransferase: This finding is consistent with HELLP syndrome, but not preeclampsia. Elevated liver enzymes are another hallmark of HELLP syndrome, which indicates liver damage and inflammation. Preeclampsia may cause mild elevations of liver enzymes, but not to the same extent as HELLP syndrome.

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Correct Answer is D

Explanation

Choice A rationale:

Referring the client to a nutritionist is not the most appropriate action in this situation. While nutritionists can provide valuable information on infant feeding, the client's primary concern is the inability to afford baby formula. A case manager is better suited to address the client's financial and social needs.

Choice B rationale:

Referring the client to the primary care provider is not the most appropriate action in this situation. The primary care provider may not have the resources or expertise to address the client's financial and social concerns.

Choice C rationale:

Referring the client to a pediatric nurse practitioner is not the most appropriate action in this situation. While pediatric nurse practitioners can provide healthcare for infants, they may not have the resources to address the client's financial constraints.

Choice D rationale:

Referring the client to a case manager is the most appropriate action in this scenario. A case manager can assess the client's financial situation and connect them with appropriate resources, such as government assistance programs or local charities, to help cover the cost of baby formula. Case managers specialize in coordinating care and addressing social determinants of health.

A. "We need to check the client's urine output every hour.” B. "Expect the stoma to appear pale until healing is complete.” C. "Expect the client's urine to contain clots for the first 24 hours.” D. "We will keep the client's fluid intake restricted until he is free of pain.”

Correct Answer is A

Explanation

The correct answer is A. "We need to check the client's urine output every hour."

Choice A rationale:

Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period.

Choice B rationale:

A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation.

Choice C rationale:

While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly.

Choice D rationale:

Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postpartum.The client tells the nurse she cannot afford to pay for baby formula.The nurse should refer the client to which of the following members of the interprofessional team?

Correct Answer is D

Explanation

A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?

Correct Answer is A

Explanation

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A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse should place the client in which of the following positions?

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