Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
75. A client, who is 19 years old, gravida 1, para 0, is admitted to labor and delivery at 30 weeks' gestation. The client reports nausea and vomiting, epigastric pain, and a headache. Her vital signs are temperature: 98.8°F, pulse: 78, respirations: 20, and blood pressure: 170/110 mm Hg. Her laboratory values are as follows: WBC: 4.5, hematocrit: 30, platelets: 88,000, AST: 146, ALT: 120. What other assessments should a nurse perform on this client?
Select all that apply.
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Test-Taking Tip
The key to answering this question is to determine what the diagnosis is for this client, which is based on vital signs and laboratory values. Choosing the correct answers depends on recognizing that this client has HELLP syndrome. Remember that HELLP stands for: decreased hematocrit, elevated liver function tests, and low platelets.
Content Area: Maternity, Antepartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
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Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because this client has HELLP syndrome, with a decreased hematocrit, elevated liver function tests, and low platelets. Deep tendon reflexes are an essential part of an assessment for a client with HELLP syndrome. Answer 2 is incorrect because a sterile vaginal examination is not an essential part of assessing a client with HELLP syndrome. The client is not complaining of abdominal pain or contractions; therefore, performing a vaginal examination is not necessary. Answer 3 is incorrect because sterile speculum examination is not an essential part of assessing a client with HELLP syndrome. The client is not complaining of abdominal pain, contractions, or leaking amniotic fluid; therefore, performing a sterile speculum examination is not necessary. Answer 4 is incorrect because a fern test is a test for rupture of amniotic membranes. The client is not complaining of leaking fluid; therefore, a fern test is not necessary. Answer 5 is correct because this client has HELLP syndrome, with a decreased hematocrit, elevated liver function tests, and low platelets. Urine protein is an essential assessment for a client with HELLP syndrome.
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