A nurse is assessing a client at 28 weeks gestation who is pregnant with twins. Which assessment finding would be most concerning and require immediate intervention?
1Fundal height measuring 32 cm at 28 weeks gestation
2Maternal weight gain of 35 pounds since conception
3Mild ankle edema at the end of the day
4Blood pressure of 160/100 mmHg with 3+ proteinuria✓ 정답
해설
Blood pressure of 160/100 mmHg with 3+ proteinuria indicates severe preeclampsia, a life-threatening condition requiring immediate intervention in twin pregnancies. Other findings (fundal height, weight gain, mild edema) are common or expected in twin gestation and do not require urgent action.
Clinical Judgment
This question assesses the ability to differentiate between normal changes in a twin pregnancy and danger signs requiring immediate intervention. The core is identifying signs of preeclampsia with severe features. The blood pressure of 160/100 mmHg and 3+ proteinuria in option 4 clearly meet the diagnostic criteria for severe preeclampsia, an emergency requiring Notify HCP!. Twin pregnancies carry a higher risk of preeclampsia, and these signs pose an immediate threat to both the mother (seizures, cerebral hemorrhage, organ failure) and the fetus (intrauterine growth restriction, placental abruption).
Memory Tip:
Remember BP Protein Preeclampsia. For twins, think Triple the Threat. When high blood pressure (BP) and proteinuria (Protein) appear together, suspect preeclampsia (Preeclampsia); the higher the values, the more emergent the situation.
KR vs US
While magnesium sulfate use is common for preeclampsia management in Korea, the US NGN/CJMM tends to emphasize more active monitoring and intervention (e.g., inpatient observation, steroid administration) even at the mild preeclampsia stage, before reaching severe criteria (BP ≥160/110, severe proteinuria). Also, proteinuria quantification (24-hour urine protein) is used as a more precise assessment tool.
Clinical Practice GuideNormal findings in a mother with a dichorionic diamniotic twin pregnancy: The fundal height (Option 1, 32 cm) is within the expected range for a twin pregnancy (singleton standard: weeks of gestation ±2 cm; twins are about 4–6 cm larger). Weight gain (Option 2, 35 lb ≈ 16 kg) is also within the recommended range for twin pregnancies. Mild peripheral edema (Option 3) is a common physiological phenomenon in the third trimester, especially in multiple pregnancies.CautionIn SATA (Select All That Apply) questions, when instructed to choose the "most concerning" finding, all options may seem somewhat problematic, but you must select one based on an immediate, life-threatening risk. Signs of preeclampsia always take priority over other relatively normal or chronic issues.
Preeclampsia with severe features — Severe preeclampsia. A condition occurring after 20 weeks of pregnancy, characterized by newly developed hypertension (systolic ≥160 mmHg or diastolic ≥110 mmHg) along with severe proteinuria (urine dipstick 3+ or higher) or other organ dysfunction (liver, kidney, neurological symptoms, thrombocytopenia, pulmonary edema, etc.).
Dichorionic Diamniotic (DCDA) twins — Fraternal twins where each fetus has its own placenta (chorion) and amniotic sac (amnion). Monitoring is necessary, but the risk of complications (e.g., twin-to-twin transfusion syndrome) is lower compared to monochorionic twin pregnancies.
Proteinuria — Proteinuria. The abnormal excretion of protein in the urine. It is one of the major diagnostic criteria for preeclampsia during pregnancy, with a urine dipstick test result of 1+ or higher suggesting suspicion, and 3+ or higher indicating severe condition.
Fundal height — Fundal height. The distance from the upper edge of the pubic symphysis to the fundus of the uterus, measured in centimeters. It generally corresponds approximately to the gestational age in weeks (±2 cm), but it may be larger in cases such as twin pregnancy or polyhydramnios.
HELLP syndrome — A severe complication of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelets. It can be life-threatening and requires emergency delivery.