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":"B"},"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. HELLP may occur without hypertension.

• 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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Refrain from using a tether strap on the car seat for children under 1 year of age: Tether straps are generally used for forward-facing car seats to reduce forward movement in a crash. Infants under 1 year should be in rear-facing seats, where tethers are not typically applicable, but the focus should be on proper rear-facing installation rather than avoiding tethers altogether.

B. Manual shoulder belts in the front seat are acceptable for school-age children over 8 years of age: Children under 13 years should ride in the back seat whenever possible, as front-seat placement increases the risk of injury from airbags and seat belts. Using front seats is not recommended solely based on age.

C. Restrict using rear-facing car seats for children after 1 year of age: Current guidelines recommend keeping children in rear-facing seats as long as possible, typically until at least age 2 or until they reach the height and weight limits of the rear-facing seat. Restricting rear-facing use at 1 year is outdated and unsafe.

D. Booster seats with belt-positioning should be used for school-age children until 8 years of age: Booster seats help position the seat belt correctly over a child’s shoulder and lap, reducing the risk of injury in a crash. This is consistent with current safety guidelines and supports proper seat belt use until the child is tall enough and meets weight requirements for adult seat belts.

A. Administer an antibiotic to the child for 10 days. B. Cyclophosphamide can be given to decrease the duration of the infection. C. Wear an N95 mask when in direct contact with the child. D. RSV is transmitted by direct contact with respiratory secretions.

Correct Answer is D

Explanation

A. Administer an antibiotic to the child for 10 days: RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics are only indicated if a secondary bacterial infection develops. Routine antibiotic therapy does not treat RSV and should not be included in teaching.

B. Cyclophosphamide can be given to decrease the duration of the infection: Cyclophosphamide is an immunosuppressive chemotherapy agent and has no role in treating RSV. Administering this medication would be inappropriate and harmful in a child with a viral respiratory infection.

C. Wear an N95 mask when in direct contact with the child: Standard precautions for RSV involve contact and droplet precautions, typically including a surgical mask, gloves, and gown. An N95 mask is not required for routine care of RSV, as transmission risk is primarily via contact with secretions and large respiratory droplets.

D. RSV is transmitted by direct contact with respiratory secretions: RSV spreads through close contact with contaminated secretions from coughing, sneezing, or touching surfaces. Teaching guardians about transmission helps prevent spread and reinforces the importance of hand hygiene and infection control measures in the home.

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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 nurse is teaching a group of parents about car seat safety. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is providing teaching to the guardians of a child who has respiratory syncytial virus (RSV). Which of the following information should the nurse include?

Correct Answer is D

Explanation

A nurse is reviewing medication prescriptions for a group of clients. Which of the following prescriptions should the nurse verify with the provider?

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

A nurse is caring fora postoperative client following a perineal prostatectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is teaching a client about routine prenatal testing, which of the following statements should the nurse include in the teaching?

A nurse is preparing to administer an intramuscular injection to a client. Which of the following injection sites should the nurse choose to utilize?

A charge nurse is discussing communication techniques to use with a client who has expressive aphasia with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates the teaching was effective?

A nurse is planning care for multiple children on a pediatric unit who have gastroesophageal reflux. Which of the following children requires a revision to their plan of care?

A nurse is preparing to administer an IM medication to a client. The nurse is unfamiliar with this medication. Which of the following actions should the nurse take?

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.