The nurse is reviewing labs on a new admit. The client's hemoglobin is 8.0; platelets are 75,000, AST 75. Which nursing action is best?
1. Contact the physician.
2. Request the labs to be redrawn.
3. Assess blood pressure.
4. Determine the client's blood type and Rh.
1
Rationale:
1. This client has HELLP syndrome, a life-threatening condition. Further orders are needed from the physician.
2. Redrawing the labs is not the best action; acting on the labs that indicate HELLP is a higher priority.
3. The labs indicate HELLP syndrome. The blood pressure is likely to be high, but notifying the physician of this life-threatening set of labs is a higher priority.
4. Although blood type and RH would need to be known after delivery to determine if the client requires RhoGAM, this is not the highest priority.
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