The nurse is continuing to care for the client.

The nurse is reviewing the assessment findings.

For each assessment 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

Alanine aminotransferase (ALT)

Platelet count

Answer and Explanation

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

Rationale for correct choices

• Blood pressure: The client’s blood pressure readings are consistently elevated (162/112 mm Hg and 166/110 mm Hg), which is a hallmark of preeclampsia. Hypertension arises from abnormal placental development leading to systemic vasoconstriction. Elevated blood pressure is a primary diagnostic criterion for preeclampsia and is more directly indicative of this condition than HELLP syndrome alone.

• Hemoglobin: The client’s hemoglobin is mildly elevated at 18 g/dL with a hematocrit of 35%, suggesting hemoconcentration and potential microangiopathic hemolysis, a component of HELLP syndrome. While preeclampsia may cause mild hemoconcentration, hemolysis is a defining feature of HELLP. This reflects red blood cell destruction associated with this syndrome.

• Alanine aminotransferase (ALT): ALT is slightly elevated at 40 units/L, reflecting liver involvement. Liver enzyme elevation can occur in severe preeclampsia due to hepatic ischemia and in HELLP syndrome due to hepatocellular injury from hemolysis and microvascular obstruction. The finding supports involvement in both conditions.

• Platelet count: The platelet count is low at 98,000/mm³, which can result from platelet activation and consumption in both preeclampsia and HELLP syndrome. Thrombocytopenia is a hallmark of HELLP syndrome and may also develop in severe preeclampsia. This finding indicates increased risk for bleeding and warrants prompt intervention and monitoring.

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Correct Answer is D

Explanation

A. A 32-year-old client who has chlamydia: Chlamydia is a sexually transmitted infection that is not transmitted via airborne or droplet routes. Standard precautions are sufficient, and a private room is not required.

B. A 50-year-old client who has Candida albicans: Candida infections are generally superficial and not highly contagious. Standard precautions are adequate, so a private room is not necessary.

C. A 25-year-old client who has vaginal trichomonas: Trichomoniasis is a sexually transmitted infection and does not require isolation. Standard precautions are appropriate for this client.

D. A 40-year-old client who has streptococcal pharyngitis: Streptococcal pharyngitis is transmitted via respiratory droplets. Placing the client in a private room or with another client who has the same infection helps prevent transmission, making a private room the most appropriate assignment.

A. Assess for bladder distention B. Apply supplemental oxygen via nonrebreather mask. C. Administer intramuscular methylergonovine. D. Analyze coagulation studies.

Correct Answer is A

Explanation

A. Assess for bladder distention: A full bladder can prevent the uterus from contracting effectively, leading to a boggy fundus and increased risk of postpartum hemorrhage. Assessing and addressing bladder distention is the priority because it directly impacts uterine tone and hemorrhage prevention.

B. Apply supplemental oxygen via nonrebreather mask: Oxygen may be necessary if the client shows signs of hypoxia or shock, but it does not address the primary cause of a boggy uterus. The priority is to correct the underlying issue affecting uterine contraction.

C. Administer intramuscular methylergonovine: Methylergonovine is used to promote uterine contraction, but pharmacologic intervention should follow initial assessment to identify reversible causes such as bladder distention. Administering medication without assessment could overlook a correctable mechanical issue.

D. Analyze coagulation studies: Coagulation studies are important if bleeding persists or coagulopathy is suspected, but they are not the immediate priority in a client with a boggy fundus shortly after birth. Immediate interventions to promote uterine contraction take precedence.

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The nurse is continuing to care for the client. The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is preparing to admit four new clients to the unit. Which of the following clients should the nurse assign to a private room?

Correct Answer is D

Explanation

A nurse is monitoring a client following a cesarean birth 6 hr ago who received an IV bolus oxytocin immediately after birth but continues to have a boggy fundus. Which of the following should the nurse identify as the priority intervention?

Correct Answer is A

Explanation

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The nurse is continuing to care for the client.

The nurse is reviewing the assessment findings.

For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.