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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The correct answer is choice B and C.
Choice A rationale:
Cervical insufficiency is a condition where the cervix begins to shorten and open too early during pregnancy, leading to premature birth or loss of an otherwise healthy pregnancy. However, the client’s symptoms do not indicate cervical insufficiency. There are no reports of lower abdominal pressure, mild pelvic cramps, or a change in vaginal discharge, which are common symptoms of cervical insufficiency.
Choice B rationale:
The client’s severe headache unrelieved by acetaminophen, +3 pitting edema in bilateral lower extremities, and hyperactive reflexes (patellar reflex 4+) are indicative of severe preeclampsia. One of the complications of severe preeclampsia is seizures, also known as eclampsia. Therefore, the client is at risk for developing seizures.
Choice C rationale:
Placental abruption is a serious pregnancy complication in which the placenta detaches from the uterus prematurely. The client’s report of decreased fetal movement could be a sign of placental abruption. In addition, severe preeclampsia can increase the risk of placental abruption. Therefore, the client is at risk for developing placental abruption.
Choice D rationale:
Heart failure occurs when the heart can’t pump enough blood to meet the body’s needs. While preeclampsia can eventually affect many organ systems including the cardiovascular system, there are no immediate signs of heart failure in the client’s symptoms.
Choice E rationale:
Hypoglycemia refers to low blood sugar levels. The client’s symptoms do not suggest hypoglycemia. Symptoms of hypoglycemia typically include confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart or irregular heartbeat, sweating, trembling or tremors, and weakness. In conclusion, based on the client’s symptoms and clinical presentation, she is at greatest risk for developing seizures (Choice B) and placental abruption (Choice C) due to severe preeclampsia.
Correct Answer is B
Explanation
Choice A rationale:
"Instruct the client to take a brisk walk." Rationale: This action is not appropriate for a pregnant client experiencing dizziness, a racing heart, and pallor while lying on their back. It may exacerbate their symptoms and is not recommended.
Choice B rationale:
"Position the client on their left side." Rationale: This is the correct action to take. The client's symptoms, such as dizziness, racing heart, and pallor, suggest that they may be experiencing supine hypotensive syndrome, a common issue in pregnancy. Placing the client on their left side helps relieve pressure on the inferior vena cava, improving blood flow to the fetus and reducing symptoms.
Choice C rationale:
"Check the client's temperature." Rationale: Checking the client's temperature is not the most relevant action to address the reported symptoms. Dizziness, racing heart, and pallor are not typically associated with fever.
Choice D rationale:
"Provide the client with a glass of orange juice." Rationale: While providing orange juice can be helpful in some cases of low blood sugar (hypoglycemia), it is not the primary intervention for a pregnant client with the reported symptoms. These symptoms are more indicative of supine hypotensive syndrome, and the priority is to change the client's position to alleviate the condition.
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