A 28-year-old primigravida at 34 weeks gestation presents to the labor and delivery unit with complaints of severe headache, visual disturbances, and epigastric pain. Her blood pressure is 168/110 mmHg, and she has 3+ proteinuria. Which assessment finding would be MOST concerning and require immediate intervention?
1Decreased fetal movement reported by the client over the past 2 hours
2Blood pressure reading of 170/112 mmHg on repeat measurement
3Complaint of blurred vision and seeing "spots" before her eyes
4Hyperreflexia with sustained clonus lasting more than 3 seconds✓ 정답
해설
Hyperreflexia with sustained clonus indicates severe CNS irritability and imminent risk of eclamptic seizures, requiring immediate magnesium sulfate and seizure precautions. Other findings are concerning but less urgent in this context.
The client presents with classic manifestations of severe preeclampsia: severe-range hypertension (168/110 mmHg), 3+ proteinuria, severe headache, visual disturbances, and epigastric pain. While all assessment findings warrant attention, the question asks which is most concerning and requires immediate intervention. This demands application of the "airway, breathing, circulation" and "safety/risk reduction" frameworks central to NCLEX-RN prioritization, specifically recognizing the progression from severe preeclampsia to eclampsia.
Analysis of the Correct Answer
Option 4: Hyperreflexia with sustained clonus lasting more than 3 seconds.
This finding represents severe central nervous system (CNS) irritability and is a direct precursor to eclamptic seizures. Sustained clonus indicates that the neuromuscular junction is in a hyper-excitable state, and the threshold for generalized tonic-clonic seizure activity is critically low. Eclampsia is a life-threatening obstetric emergency associated with maternal hypoxia, aspiration, placental abruption, and fetal distress. Magnesium sulfate is the first-line agent for seizure prophylaxis in severe preeclampsia precisely to suppress this CNS hyperexcitability [1,2]. A finding of sustained clonus signals that seizure activity is imminent, making it the highest priority for immediate pharmacologic intervention to ensure maternal safety.
Why Other Options Are Lower Priority
- Option 1: Decreased fetal movement. This is a highly concerning sign for fetal well-being, potentially indicating uteroplacental insufficiency. The pathophysiologic basis of preeclampsia involves abnormal placentation and systemic vasospasm, which reduces placental perfusion. Delivery timing is the critical decision in preeclampsia management to balance maternal and fetal risks [3]. However, in the acute setting, the mother's life takes priority. A maternal seizure would catastrophically compromise both maternal and fetal oxygenation. Stabilizing the maternal CNS status is the immediate prerequisite before addressing fetal concerns.
- Option 2: Blood pressure reading of 170/112 mmHg. This confirms severe-range hypertension, which requires urgent antihypertensive therapy with agents such as IV labetalol or oral nifedipine to prevent maternal cerebrovascular accident [1,2]. The goal is to lower blood pressure to a safe range (typically 140-160/90-105 mmHg) without causing hypotension. While this is an urgent intervention, it is secondary to preventing an active, impending seizure. The blood pressure reading represents a risk factor for a stroke, whereas sustained clonus represents the final common pathway to an active seizure.
- Option 3: Blurred vision and seeing "spots." These visual disturbances are classic symptoms of severe preeclampsia, resulting from retinal arteriolar vasospasm and cerebral edema. They are part of the diagnostic criteria for severe features and indicate end-organ damage. However, they are not an immediate harbinger of a life-threatening event in the same way that sustained clonus is. The presence of these symptoms reinforces the diagnosis and the need for delivery planning [3], but they do not demand the same split-second intervention as a premonitory sign of eclampsia.
References (research sources)
[3]
Predicting interval from diagnosis to delivery in preeclampsia using electronic health records.Research articleYang X, Ballard HK, Mahadevan AD, Xu K, Garmire DG, Langen ES, Lemas DJ, Garmire LX. (2025) · DOI: 10.1038/s41467-025-58437-7
Clinical Scenario
A 28-year-old primigravida at 34 weeks gestation with severe preeclampsia (BP 168/110 mmHg, 3+ proteinuria, headache, visual disturbances, epigastric pain) develops hyperreflexia with sustained clonus (>3 seconds). This finding indicates severe CNS irritability and imminent risk of eclamptic seizure.
Immediate Nursing Action
Initiate seizure precautions: pad side rails, ensure suction and oxygen are functional, and lower the bed.
Administer magnesium sulfate as ordered (typically a loading dose of 4-6 g IV over 15-20 minutes, followed by a maintenance infusion of 1-2 g/hour).
Monitor for magnesium toxicity: assess patellar reflexes hourly, respiratory rate, urine output, and serum magnesium levels (therapeutic range 4-7 mg/dL).
Keep calcium gluconate at the bedside as the antidote for magnesium toxicity.
Notify the provider immediately and prepare for potential emergency delivery if maternal or fetal status deteriorates.
Clinical Reasoning
Sustained clonus is a motor sign of neuromuscular hyperexcitability that directly precedes a generalized tonic-clonic seizure. Eclamptic seizures cause maternal hypoxia, aspiration, placental abruption, and fetal bradycardia. Prioritizing this finding over blood pressure elevation or visual symptoms follows the ABC framework, as seizure activity compromises the airway and breathing. Magnesium sulfate is the definitive intervention to prevent this progression.
Key Practice Points
In severe preeclampsia, CNS signs like hyperreflexia and clonus take priority over hypertension or fetal status changes because they herald eclampsia.
Magnesium sulfate is for seizure prophylaxis, not for treating hypertension; antihypertensives (e.g., labetalol, hydralazine) are used for severe-range blood pressure.
Always assess deep tendon reflexes, respiratory rate, and urine output before and during magnesium sulfate infusion to detect toxicity early.
Sustained Clonus — Involuntary, rhythmic muscle contractions that persist beyond a few beats, indicating severe central nervous system hyperexcitability and a high risk for seizure activity.
Eclampsia — The onset of generalized tonic-clonic seizures in a woman with preeclampsia, a life-threatening obstetric emergency requiring immediate management.
Magnesium Sulfate — The first-line anticonvulsant medication used for seizure prophylaxis and treatment in severe preeclampsia and eclampsia to reduce CNS irritability.
Severe Preeclampsia — A hypertensive disorder of pregnancy characterized by blood pressure ≥160/110 mmHg, proteinuria, and often signs of end-organ damage such as CNS or hepatic involvement.
Airway, Breathing, Circulation (ABC) — A systematic prioritization framework in emergency care where life-threatening airway and breathing issues, such as seizure activity, take precedence over circulatory or fetal concerns.