QUESTION: "Accompanied by her mother, a 16-year-old unmarried primigravida at 35 weeks' gestation in active labor with severe pre-eclampsia is admitted to the hospital's labor unit. While caring for this client, the nurse would notify the physician immediately for which of the following findings?"
CHOICES
( X ) a.) 2+ deep tendon reflexes.
( X ) b.) 3+ proteinuria.
( O ) c.) Platelet count of 80,000/mL.
( X ) d.) Clear to whitish vaginal discharge.
RATIONALE: A platelet count of less than 100,000 /mL indicates thrombocytopenia, a component of HELLP syndrome. HELLP syndrome, which consists of hemolysis, elevated liver enzymes, and low platelet count (below 100,000 /mL), is associated with severe pre-eclampsia. Notifying the physician immediately is crucial because this syndrome is associated with high rates of morbidity and mortality for the mother and her offspring. Deep tendon reflexes of 2+ are normal and not a cause of concern. The client has severe pre-eclampsia so proteinuria of 3+ to 4+ would be expected. A clear to whitish vaginal discharge is a normal finding. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
