A patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate

Correct Answer: D

Rationale: The correct answer is D because the symptoms described (headache, visual changes, epigastric pain) are classic signs of worsening preeclampsia, indicating impending eclampsia with seizures. This requires urgent intervention to prevent serious complications. Option A is incorrect as gastrointestinal upset does not typically present with these specific signs. Option B is incorrect as magnesium sulfate is used to prevent seizures in preeclampsia, not cause the symptoms described. Option C is incorrect as anxiety would not cause the specific symptoms mentioned. In summary, the signs described point towards worsening disease and the likelihood of impending convulsions, necessitating immediate medical attention.

Correct Answer: B

Rationale: The correct answer is B: Administer calcium gluconate. This is because magnesium sulfate can lead to respiratory depression by inhibiting neuromuscular transmission. Calcium gluconate is the antidote as it competes with magnesium for binding sites, reversing its effects. Increasing IV fluids (A) is not directly related to addressing respiratory depression. Vigorously stimulating the patient (C) can exacerbate respiratory depression. Instructing the patient to take deep breaths (D) may not be effective in addressing respiratory depression caused by magnesium sulfate.

Correct Answer: A

Rationale: The correct answer is A: Platelet count of 50,000/mcL. In HELLP syndrome, there is hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 50,000/mcL indicates thrombocytopenia, a key feature of HELLP syndrome. It signifies ongoing coagulation abnormalities and liver dysfunction. B: Liver enzyme levels within normal range is incorrect as HELLP syndrome typically presents with elevated liver enzymes. C: Negative for edema is incorrect as edema is not a defining characteristic of HELLP syndrome. D: No evidence of nausea or vomiting is incorrect as these symptoms are not specific to HELLP syndrome.

Correct Answer: C

Rationale: The correct answer is C because bleeding at the IV insertion site could indicate disseminated intravascular coagulation (DIC), a major complication of placental abruption. DIC is a serious condition that results in widespread clotting and bleeding throughout the body. This finding signifies that the patient's clotting factors are being consumed rapidly, leading to uncontrolled bleeding. Options A, B, and D are not indicative of a major complication of placental abruption. A decreased urine output, low blood pressure, and normal respiratory rate may be seen in various conditions but are not specific to DIC or a major complication in this context.

Correct Answer: C

Rationale: The correct answer is C: Clear fluid from vagina. In threatened abortion, the pregnancy is at risk but the fetus is still viable. In inevitable abortion, there is no chance of continuation. Clear fluid from the vagina indicates rupture of membranes, leading to inevitable abortion due to the loss of amniotic fluid. Backache, rise in hCG levels, and pelvic pressure are common symptoms in threatened abortion but do not definitively indicate progression to inevitable abortion.