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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.
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C,D
Rationale: Sure, here is the step-by-step rationale for why options C and D (Platelet count) are correct:
1. Blood pressure: In preeclampsia, high blood pressure is a key characteristic. Elevated blood pressure is a common finding in patients with preeclampsia, making option C consistent with preeclampsia.
2. Platelet count: HELLP syndrome is a serious complication of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. Therefore, a low platelet count is a hallmark feature of HELLP syndrome, aligning with option D.
Summary:
- Hemoglobin (Option A): Hemoglobin levels are not specific to either preeclampsia or HELLP syndrome. Therefore, this option is not selected.
- Alanine aminotransferase (ALT) (Option B): Elevated ALT levels are more specific to HELLP syndrome due to liver involvement. However, ALT
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Select the 5 actions the nurse should take.
- A. Increase the flow rate of the maintenance IV fluid.
- B. Have the charge nurse notify the provider.
- C. Place the client in a Trendelenburg position.
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix.
- F. Administer oxygen at 10 L/min Via nonrebreather face mask
Correct Answer: A,B,C,D,E
Rationale: Correct Answer: A, B, C, D, E
Rationale:
A: Increasing IV fluid flow rate helps maintain hydration and blood pressure.
B: Notifying the provider ensures timely medical intervention and documentation.
C: Placing the client in Trendelenburg position helps improve placental perfusion.
D: Exerting upward pressure on presenting part can alleviate pressure on the cord.
E: Attempting to push the umbilical cord back can prevent cord compression and fetal distress.
Summary:
F: Administering oxygen may be beneficial but not among the immediate actions required.
G: No information provided about this choice.
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Anticipate administering prescribed immunosuppressant medications
- B. Ensure that client has intake of at least 200 ml/hr
- C. Encourage client to avoid direst sunlight
- D. Initiate contact precautions
- E. Prepare client for light therapy
- F. Sickle cell crisis
- G. Psoriasis
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.
Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer Ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: B,C,F
Rationale: Administering pain relief, protecting the abrasion, and elevating the limb reduce swelling and promote comfort.
Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. kidney function tests
- C. hemoglobin and hematocrit
- D. serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.