NCLEX Blog / Maternity, Newborn & Pediatrics / Preeclampsia vs HELLP on the NCLEX: Findings and First Actions
Preeclampsia vs HELLP on the NCLEX: Findings and First Actions

Preeclampsia vs HELLP on the NCLEX: Findings and First Actions

By Dr. Jamila Abudheil, PhD, RN·9 min read·Updated 2026-10-06
The short answer

Preeclampsia is new hypertension at or after 20 weeks with proteinuria or end-organ signs; HELLP syndrome adds Haemolysis, Elevated Liver enzymes and Low Platelets and can occur even without severe hypertension. Right upper quadrant or epigastric pain is the finding that should raise HELLP, and magnesium sulfate is given for seizure prophylaxis, not to lower blood pressure.

Preeclampsia, Eclampsia and HELLP▶ Watch this lesson
Preeclampsia, Eclampsia and HELLP

Free sample lesson: preeclampsia, eclampsia and HELLP, with magnesium sulfate and its toxicity.

From the Intensive NCLEX Course. This lesson is a free sample: watch it with a free account.

Preeclampsia questions turn on recognising the point at which "monitor closely" becomes "act now". HELLP is that point, and so is magnesium toxicity — both are recognisable from a small set of findings the exam reuses.

Step 1 — The spectrum

PreeclampsiaWith severe featuresHELLPEclampsia
Blood pressure≥ 140/90 after 20 weeks≥ 160/110May be only mildly raisedRaised
ProteinPresentPresentPresentPresent
Key extra findingsOedema, weight gainHeadache, visual changes, epigastric or RUQ pain, low platelets, rising creatinineHemolysis, Elevated Liver enzymes, Low PlateletsSeizure
What it meansMonitor closelyDeliver, usuallyEmergency — organ damage under wayEmergency

The three severe features to react to

Headache that will not settle. Visual changes — blurring, spots, flashing. Epigastric or right upper quadrant pain. These are not discomforts of pregnancy in this context: the headache signals cerebral irritability and impending seizure, and the epigastric pain is the liver. Any of the three in a preeclamptic client is a reportable emergency finding.

Step 2 — HELLP, and why it is missed

HELLP is a laboratory diagnosis. The blood pressure can be almost unremarkable, so a client can look less sick than she is.

LetterLabMeaning
HemolysisFalling haemoglobin, rising bilirubinRed cells are being destroyed
Elevated Liver enzymesAST and ALT upLiver injury — this is the epigastric pain
Low PlateletsUnder 100,000Bleeding risk — the most dangerous element

The consequence of the low platelets is what the exam tests: bleeding precautions. No intramuscular injections where avoidable, pressure held longer at puncture sites, soft toothbrush, watch for petechiae and bleeding gums, and epidural anaesthesia may be contraindicated.

Step 3 — Magnesium sulfate, and its toxicity

Magnesium is given to prevent seizures, not to lower blood pressure. That distinction gets asked directly.

MonitorReassuringStop the infusion and notify
Deep tendon reflexesPresentAbsent — the earliest sign of toxicity
Respiratory rateOver 12/minUnder 12/min
Urine outputAt least 30 mL/hrUnder 30 mL/hr — magnesium is excreted renally and will accumulate
Level of consciousnessAlert, mildly flushed and warm is expectedIncreasing drowsiness, slurred speech

The antidote is calcium gluconate, and it should be at the bedside whenever magnesium is running. Expect the exam to ask for it by name.

Order of the signs, which is the question underneath the question: reflexes go first, then respirations, then cardiac. So an absent patellar reflex with a respiratory rate of 14 is early toxicity — act on the reflex rather than waiting for the breathing to fall.

Monitoring a client on a magnesium sulfate infusion: deep tendon reflexes, respiratory rate, urine output and serum magnesium level, with calcium gluconate as the antidote
The four checks on magnesium: reflexes present, respirations at least 12, urine output at least 30 mL per hour, level in range. Lost reflexes come first; calcium gluconate is the antidote.

Step 4 — If she seizes

Eclampsia. In order:

  1. Stay with her and turn her to her side. Do not leave, do not restrain, do not put anything in her mouth.
  2. Protect the airway — suction available, oxygen ready.
  3. Call for help without leaving the bedside.
  4. Note the time and duration; magnesium is given or increased per orders.
  5. Assess the fetus after the seizure, not during — you cannot help the fetus while the mother is unprotected.

The environment matters beforehand: seizure precautions mean a quiet, dim room, side rails padded and up, suction and oxygen at hand, and minimal disturbance. An option offering to "reduce stimulation" in a client with severe features is usually correct.

It does not end at delivery

Postpartum preeclampsia and eclampsia are real, and seizures can occur up to 48 hours or more after birth. Magnesium is typically continued for 24 hours postpartum, and a discharged client needs teaching about headache, visual changes and epigastric pain.

NCLEX tip: Magnesium sulfate prevents seizures — it is not an antihypertensive. And check reflexes before anything else: they disappear before the respiratory rate falls, which makes them the earliest warning you have.

Practice

5 NCLEX practice questions on this topic

The same questions, player and partial-credit scoring students use inside NCLEXPace: answer, submit, read the full rationale, then Next. Your score is waiting at the end. No account needed for these.

Question 1 of 5Score: 0%
Question 1 of 5Multiple Choice

Select the best answer.

A client at 12 weeks of gestation whose previous pregnancy ended in preterm birth because of severe preeclampsia asks whether anything can lower her risk this time. Which prescription should the nurse anticipate?

Question 2 of 5Matrix / Grid (NGN)

For each finding, indicate whether it indicates preeclampsia with severe features or does not by itself indicate severe features.

A client at 34 weeks of gestation has a blood pressure of 152/98 mm Hg and 2+ proteinuria and is being evaluated for preeclampsia. For each additional finding, indicate whether it indicates preeclampsia with severe features or does not by itself indicate severe features.

Indicates severe featuresDoes not by itself indicate severe features
Persistent headache with flashing lights unrelieved by acetaminophen
Platelet count of 85,000/mm3
Mild bilateral ankle edema at the end of the day
Urine protein of 3+ on dipstick
Blood pressure of 164/112 mm Hg on two readings 4 hours apart
Note: Each row must have 1 response option selected.
Question 3 of 5Multiple Choice

Select the best answer.

A client's prenatal record shows that she is not immune to rubella. She is Rh negative and received Rh immune globulin this morning. Which instruction should the nurse include before discharge?

Question 4 of 5Multiple Choice

Select the best answer.

Four clients with a history of cesarean birth are being counseled about a trial of labor in the current pregnancy. Which client is the most appropriate candidate?

Question 5 of 5Select-All-That-Apply (SATA)

Select all that apply.

At a home visit on the sixth day after birth, the nurse evaluates whether an exclusively breastfed infant is getting enough milk. Which findings indicate adequate intake? Select all that apply.

Select all that apply.
0 answered · 0%
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Frequently asked questions

Common follow-up questions on Maternity, Newborn & Pediatrics.

What does HELLP stand for?

Haemolysis, Elevated Liver enzymes, and Low Platelets. It is a severe variant of preeclampsia and may present with relatively modest blood pressure elevation, which is what makes it dangerous to miss.

What are the signs of severe preeclampsia?

Blood pressure of 160/110 mmHg or higher, severe headache unrelieved by analgesia, visual disturbances, right upper quadrant or epigastric pain, hyperreflexia with clonus, oliguria, and a platelet count below 100,000/mm³.

What must be monitored during magnesium sulfate infusion?

Deep tendon reflexes, respiratory rate, urine output and level of consciousness. Loss of patellar reflexes is the earliest warning of toxicity, followed by respiratory depression below 12 breaths per minute and urine output under 30 mL per hour. Calcium gluconate is the antidote and must be immediately available.

Why is epigastric pain significant in preeclampsia?

It suggests hepatic involvement from liver capsule distension and is a warning sign of HELLP syndrome or impending eclampsia. It is treated as an emergency finding requiring immediate provider notification, not as indigestion.

Sources and references

  1. Lowdermilk DL, Perry SE, Cashion K, Alden KR, Olshansky EF. Maternity & Women's Health Care. 12th ed. Elsevier; 2020; Chapter: Hypertensive Disorders.
  2. American College of Obstetricians and Gynecologists. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin No. 222. Obstetrics & Gynecology. 2020;135(6):e237-e260.

Reviewed by the NCLEXPace team, October 2026.

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