Practice Question
A patient had repeat cesarean birth 3days ago.
Answer Choices:
Rationale:
Client reports ringing in ears — Indication of Worsening Condition
💎 Tinnitus (ringing in the ears) is a classic warning sign of severe hypertension in preeclampsia and HELLP syndrome.
💎 It occurs due to cerebral vasospasm and increased intracranial pressure, reflecting neurological irritation and reduced cerebral perfusion.
💎 Persistent or worsening ringing may precede seizure activity (eclampsia), indicating worsening central nervous system involvement.
💎 The nurse must immediately monitor blood pressure, assess for headache or visual changes, and prepare for antihypertensive and seizure prophylaxis (e.g., magnesium sulfate).
FHR 80/min with absent variability — Indication of Worsening Condition
💎 A fetal heart rate (FHR) of 80/min with absent variability indicates severe fetal hypoxia or distress.
💎In HELLP syndrome, placental insufficiency results from vasoconstriction and endothelial damage, reducing oxygen and nutrient delivery to the fetus.
💎Absent variability means the autonomic nervous system of the fetus is no longer compensating, showing impending fetal compromise or death.
💎This finding requires immediate intrauterine resuscitation (positioning, oxygen, fluids) and likely emergency delivery if unresolved.
PT 12 seconds — Indication of Improving Condition
💎 A prothrombin time (PT) of 12 seconds is within the normal range (11–13.5 sec), indicating adequate liver function and clotting ability.
💎In worsening HELLP, liver dysfunction typically causes prolonged PT and bleeding tendencies.
💎A normal PT therefore reflects stabilization of hepatic enzyme activity and coagulation factors, signaling that treatment is working and liver recovery is underway.
💎It also means risk for DIC is reduced, and maternal blood loss is better controlled.
Moderate maternal bleeding — Indication of Worsening Condition
💎 In HELLP syndrome, low platelet counts and impaired coagulation increase the risk for spontaneous bleeding.
💎 Moderate bleeding can indicate the onset of DIC, where widespread clotting consumes platelets and clotting factors, leading to hemorrhage.
💎 This also places the mother at risk for hypovolemic shock, anemia, and organ failure.
💎 The nurse should immediately assess vital signs, bleeding sites, and prepare to administer platelets or plasma products per provider orders.
BP 180/100 mm Hg — Indication of Worsening Condition
💎 A blood pressure of 180/100 mm Hg demonstrates severe, uncontrolled hypertension, hallmark of worsening preeclampsia or HELLP syndrome.
💎 Such extreme pressure damages endothelial cells, worsening vascular permeability, edema, and organ ischemia (especially liver and kidneys).
💎 This level of hypertension increases the risk of stroke, placental abruption, and eclampsia.
💎 Emergency interventions include antihypertensive therapy (labetalol, hydralazine) and magnesium sulfate for seizure prevention.
Client reports sharp, stabbing abdominal pain — Indication of Worsening Condition
💎Sudden sharp, stabbing pain in the upper right quadrant or epigastric area is a hallmark sign of liver capsule distention due to subcapsular hematoma or even hepatic rupture.
💎 This is a medical emergency and indicates rapidly worsening HELLP syndrome with risk of internal bleeding and hypovolemic shock.
💎 The pain often radiates to the shoulder or back, and may be accompanied by nausea, vomiting, or hypotension as bleeding progresses.
💎 Immediate evaluation, imaging, and surgical intervention are required to prevent maternal mortality.
Want to practice more questions like this?
This question is from RN-Maternal Newborn 2023 which contains 68 questions.
More Questions from This Exam
A nurse is caring for a client who is at 35 weeks of gestation and has moderate abruptio placenta. Which of the following actions should the nurse take?
Answer Choices:
A nurse is planning care for a client who is scheduled for an amniocentesis and is Rh negative. Which of the following actions should the nurse plan to take?
Answer Choices:
A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should instruct the client to contact the provider for which of the following findings?
Answer Choices:
A nurse is caring for a newborn who is 5 days old. Which of the following actions are needed? Select all that apply.
Answer Choices:
A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Maternal & Newborn Care
- Answer Choices: 0