A nurse is assessing a 25-year-old pregnant woman at 30 weeks gestation who presents to the emergency department with complaints of severe headache and visual disturbances. Her blood pressure is 150/100 mmHg. Which assessment finding would be most indicative of preeclampsia?
1Fetal heart rate of 140 beats per minute
2Maternal temperature of 99.2°F (37.3°C)
3Blood pressure of 160/110 mmHg with 3+ proteinuria✓ 정답
4Hemoglobin level of 10.5 g/dL
해설
BP 160/110 mmHg with 3+ proteinuria meets diagnostic criteria for severe preeclampsia. Other findings (normal FHR, mild fever, mild anemia) are not specific to preeclampsia.
Core Nursing ExplanationKey Concept Analysis: This question assesses your ability to identify the diagnostic criteria for Preeclampsia, a hypertensive disorder of pregnancy. The core theme is differentiating between general pregnancy symptoms and the specific signs that confirm this serious condition. Preeclampsia is defined by new-onset hypertension (blood pressure ≥140/90 mmHg) and proteinuria (≥300 mg/24 hours or ≥1+ on dipstick) after 20 weeks of gestation. Key Point! The transition to Severe preeclampsia is marked by significantly elevated blood pressure (≥160/110 mmHg) and/or the presence of specific end-organ dysfunction symptoms (like the headache and visual changes described).
Answer Rationale: Option ③ is correct because it presents two classic, quantifiable diagnostic markers for severe preeclampsia: severe hypertension (160/110 mmHg) and significant proteinuria (3+ proteinuria). This combination, in the context of the patient's symptoms (severe headache, visual disturbances), strongly indicates the disease is progressing to a severe state, requiring immediate intervention.
Distractor Analysis:
Option ① (Fetal heart rate 140 bpm): A fetal heart rate (FHR) of 110-160 beats per minute is within the normal range. While FHR monitoring is crucial in preeclampsia to assess fetal well-being, a normal FHR alone does not confirm or rule out the diagnosis in the mother.
Option ② (Maternal temp 99.2°F/37.3°C): This represents a very mild elevation in temperature, which is non-specific. It is not a diagnostic criterion for preeclampsia. Infection can sometimes mimic or complicate preeclampsia, but fever is not a hallmark sign.
Option ④ (Hemoglobin 10.5 g/dL): This indicates Mild anemia, which is common in pregnancy due to hemodilution. While preeclampsia can affect hematologic parameters (e.g., causing Thrombocytopenia), a slightly low hemoglobin level is not diagnostic for the condition.
Related Concepts: It is critical to understand that preeclampsia is a multi-system disorder. Beyond hypertension and proteinuria, nurses must vigilantly assess for signs of severe features: HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), cerebral symptoms (headache, visual changes, hyperreflexia), pulmonary edema, and epigastric/RUQ pain. The ultimate goal of nursing care is early recognition to prevent progression to Eclampsia (seizures).
Indicative of cerebral edema and severe disease. A Key Point! for imminent risk of eclampsia.
Migraine, sinusitis, other neurological issues.
Epigastric/RUQ Pain
Suggests liver involvement (stretching of Glisson's capsule), part of HELLP syndrome.
Gallbladder disease, gastritis, heartburn of pregnancy.
Hyperreflexia with Clonus
Sign of central nervous system irritability.
Can be seen in other neurological conditions; baseline in some individuals.
Sudden Weight Gain & Edema
Classic but non-diagnostic sign due to fluid retention and protein loss.
Normal pregnancy edema (dependent, pits on pressure).
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Preeclampsia involves endothelial dysfunction and vasospasm, leading to hypertension, reduced organ perfusion, and capillary leak (causing proteinuria and edema).
Drug of Choice: Magnesium sulfate is the anticonvulsant used to prevent and treat eclamptic seizures. It works by blocking calcium influx and depressing CNS excitability.
Antihypertensive: Labetalol and Hydralazine are commonly used for acute blood pressure control in severe preeclampsia.
Memory Tips
Acronym for Severe Features: HELLP (Headache, Epigastric pain, Liver enzymes up, Low Platelets) – but remember, HELLP is a specific syndrome within severe preeclampsia.
Diagnosis Mnemonic: BP + P – You need both elevated Blood Pressure +Proteinuria after 20 weeks.
Priority Action: Think "MAGnet for seizures" – Magnesium sulfate is the priority medication.
High-Frequency NCLEX Topics
Preeclampsia is a High Yield topic. The NCLEX-RN frequently tests:
From Symptom to Intervention: "The nurse notes 3+ patellar reflexes and clonus in a preeclamptic patient. What is the priority action?" (Answer: Assess for other signs of MgSO4 toxicity like respiratory depression and prepare to administer calcium gluconate).
From Assessment to Medication: "A patient with severe preeclampsia has a BP of 170/115 mmHg. Which medication should the nurse anticipate administering?" (Answer: IV labetalol or hydralazine as per protocol).
Priority Patient: "The nurse is caring for four patients. Which patient requires immediate assessment?" (The one with preeclampsia complaining of a sudden, severe headache).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in a Labor & Delivery triage unit. Maria, a 30-week pregnant G1P0, is brought in by her partner. She states she has had a "pounding headache" for two days that won't go away with Tylenol, and she's seeing "spots" in her vision. She appears anxious and is holding her head.
Nursing Intervention Strategy:
Immediate Assessment (ABCs & More):
Vital Signs & Focused Assessment: Obtain an accurate BP in both arms with the patient in a left lateral position. Check for proteinuria via dipstick. Perform a Neurological assessment: Ask specifically about headache location/severity, visual changes, and assess deep tendon reflexes (DTRs) and for clonus.
Fetal Assessment: Place on continuous external fetal monitoring (EFM) to assess fetal heart rate (FHR) pattern and uterine activity.
Laboratory Work: Draw stat labs: CBC (platelet count), liver function tests (AST, ALT), serum creatinine, and uric acid.
Nursing Diagnosis & Planning:
Primary nursing diagnoses may include: Risk for Injury (maternal/fetal) related to potential seizure activity and hypertension; Acute Pain related to cerebral edema and vasospasm.
The immediate plan is to stabilize the mother, prevent seizures, control hypertension, and prepare for possible delivery—the only definitive cure for preeclampsia.
Implementation of Care:
Environment & Safety: Place the patient in a quiet, dark room to minimize stimulation. Implement seizure precautions (pad side rails, have suction and O2 available at bedside).
Medication Administration:
Magnesium Sulfate (MgSO4): Administer IV loading dose (typically 4-6g over 20-30 mins) followed by a maintenance infusion (1-2g/hr) as ordered. Key Point! Monitor closely for signs of toxicity: loss of DTRs, respiratory rate < 12/min, urine output < 30 mL/hr. Keep Calcium gluconate at the bedside as the antidote.
Antihypertensives: Administer labetalol or hydralazine per protocol for severe hypertension. Monitor BP every 5-15 minutes during and after administration.
Monitoring: Strict I&O (catheterize for accuracy). Monitor for worsening symptoms (increased headache, new pain).
Patient Safety and Precautions
Contraindications/Cautions with MgSO4: Do not administer if DTRs are absent, respiratory rate is depressed, or urine output is inadequate. Monitor serum magnesium levels.
Blood Pressure Monitoring: Avoid taking BP in the arm with the running MgSO4 infusion, as infiltration can cause tissue necrosis.
Delivery Planning: Understand that for severe preeclampsia at <30 weeks, the decision involves balancing maternal risks against fetal immaturity. Steroids (betamethasone) will likely be given to accelerate fetal lung maturity.
Educate patient/family on purpose of med and to report feeling very weak, dizzy, or having trouble breathing.
A Word from Your Senior Nurse
"Preeclampsia is one of those conditions where your nursing assessment is absolutely vital. That headache isn't 'just a headache'—it's a red flag waving at you, telling you the patient's brain is swelling. Your quick, thorough assessment and vigilant monitoring are what stand between a controlled situation and an emergency C-section for fetal distress or a maternal seizure. When you see that combination of high BP + proteinuria + neuro symptoms, your internal alarm bells should be ringing. Master this topic—it saves lives."
Preeclampsia — A hypertensive disorder of pregnancy characterized by new-onset hypertension (≥140/90 mmHg) and proteinuria (≥300 mg/24h) after 20 weeks of gestation.
Proteinuria — The presence of an excess of serum proteins in the urine; a key diagnostic criterion for preeclampsia (≥1+ on dipstick or ≥300 mg/24h).
HELLP Syndrome — A severe complication of preeclampsia involving Hemolysis, Elevated Liver enzymes, and Low Platelets.
Magnesium Sulfate — The anticonvulsant medication of choice for the prevention and treatment of seizures in preeclampsia and eclampsia.
Eclampsia — The onset of seizures in a patient with preeclampsia, representing a life-threatening obstetric emergency.