A 32-year-old multigravida at 36 weeks gestation presents wi… | 마이메르시 MyMerci
Maternal Newborn Health
문제

A 32-year-old multigravida at 36 weeks gestation presents with complaints of severe headache, blurred vision, and right upper quadrant pain. Her blood pressure is 172/114 mmHg, and she has 4+ proteinuria. Which assessment finding would be most indicative of impending eclampsia?

해설
Hyperreflexia with clonus is the key neurological sign of impending eclampsia in severe preeclampsia, necessitating urgent intervention. Other options are less specific indicators of progression.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the critical nursing skill of recognizing signs of disease progression from severe Preeclampsia to Eclampsia. The patient presents with classic symptoms of severe preeclampsia: severe headache, blurred vision (visual disturbances), right upper quadrant (RUQ) pain (indicative of hepatic involvement), severe hypertension (172/114 mmHg), and significant proteinuria (4+). The question asks for the finding most indicative of impending eclampsia, which is the progression to seizures.

Answer Rationale: Key Point! The correct answer is Hyperreflexia with clonus. In the pathophysiology of preeclampsia/eclampsia, cerebral vasospasm and edema lead to central nervous system (CNS) irritability. Hyperreflexia (exaggerated deep tendon reflexes) and clonus (a series of involuntary, rhythmic muscle contractions when a joint is quickly dorsiflexed) are direct, objective signs of this increased CNS irritability. They are considered ominous warning signs that a seizure (eclampsia) may be imminent. This finding triggers the immediate administration of magnesium sulfate (MgSO₄) for seizure prophylaxis.

Distractor Analysis:
Watch out for confusion! Decreased urine output of 400 mL in 24 hours indicates oliguria, which is a sign of severe preeclampsia due to renal involvement. However, it is not the most specific neurological sign pointing directly to impending seizures. While serious, it signals renal compromise rather than imminent CNS crisis.
Watch out for confusion! Facial edema and weight gain are common in pregnancy and can be seen in preeclampsia due to generalized edema from vascular permeability. However, they are non-specific and can occur without progression to eclampsia. Sudden, significant weight gain (e.g., >2 lbs in a week) is a warning sign, but facial edema alone is less critical than neurological signs.
Watch out for confusion! Blood pressure of 160/100 mmHg on two occasions meets the diagnostic criteria for hypertension in pregnancy. However, the patient in the scenario already has a much higher BP (172/114). This option describes a diagnostic criterion, not a new, worsening sign of impending eclampsia. The patient's condition has already progressed beyond this baseline diagnostic finding.

Related Concepts: The priority in managing severe preeclampsia is to prevent eclampsia (seizures) and other end-organ damage (HELLP syndrome, stroke, renal failure). Magnesium sulfate is the anticonvulsant of choice. Delivery of the fetus is the definitive cure for preeclampsia/eclampsia.
Concept Summary
TermDefinition & Significance
PreeclampsiaHypertension (≥140/90) with proteinuria after 20 weeks gestation.
Severe PreeclampsiaBP ≥160/110, severe proteinuria, symptoms (headache, visual changes, RUQ pain).
Impending EclampsiaThe stage just before seizures occur; marked by CNS irritability (hyperreflexia, clonus).
EclampsiaThe occurrence of grand mal seizures in a preeclamptic patient.
HELLP SyndromeA severe complication: Hemolysis, Elevated Liver enzymes, Low Platelets.

Side-by-Side Comparison!
Sign/SymptomIndicates...Nursing Implication
Hyperreflexia/ClonusCNS irritability, impending eclampsiaImmediate MgSO₄ administration; prepare for delivery.
Severe Headache/Blurred VisionCerebral edema/vasospasm (severe preeclampsia)Monitor closely for neuro changes; report immediately.
RUQ/Epigastric PainHepatic edema/swelling (may progress to HELLP)Monitor liver enzymes (AST, ALT) and platelet count.
Oliguria (

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on the labor and delivery unit. Your patient, Anna, 36 weeks pregnant, calls you to her room stating she has a "crushing" headache and sees spots. Your assessment reveals BP 168/110, 3+ proteinuria, and 3+ patellar reflexes with sustained ankle clonus.

Nursing Intervention Strategy: 1. Immediate Assessment & Safety: Place patient in a quiet, dimly lit room. Perform a focused neuro assessment: check DTRs, clonus, level of consciousness (LOC). Institute seizure precautions (pad side rails, have suction and O₂ ready). 2. Communication & Orders: Notify the provider STAT. Anticipate orders for STAT labs (CBC, liver enzymes, creatinine) and a 24-hour urine collection for total protein. 3. Medication Administration: Prepare to administer Magnesium sulfate via IV pump as ordered (typically a loading dose of 4-6 g over 20-30 minutes, followed by a maintenance infusion of 1-2 g/hour). Monitor closely for toxicity. 4. Ongoing Monitoring: Continuous fetal monitoring. Strict intake and output (I&O) – urine output must be ≥30 mL/hr. Monitor for signs of pulmonary edema (crackles, dyspnea).

Patient Safety and Precautions: * Key Point! MgSO₄ Toxicity: Assess DTRs hourly. Absent DTRs are the first sign of toxicity. Monitor respiratory rate (>12/min) and oxygen saturation. Have calcium gluconate at the bedside as the antidote. * Do not leave the patient unattended. During a seizure, do not restrain; turn patient to left lateral position to prevent aspiration and improve placental blood flow. * Avoid stimulants (e.g., loud noises, bright lights) which can trigger seizures.
Nursing Procedure & Medication Flow Administering MgSO₄: 1. Verify order and patient identity. 2. Use an IV pump for precise control. 3. Administer loading dose as prescribed (e.g., 4 g in 100 mL NS over 20 min). 4. Initiate maintenance infusion (e.g., 1 g/hr in 100 mL NS). 5. Monitoring Protocol: * Vital signs, DTRs, clonus: Every 1 hour. * Respiratory rate and effort: Every 1 hour. * Urine output: Every hour (must be ≥30 mL/hr). * Serum magnesium levels (therapeutic range: 4-7 mg/dL).
A Word from Your Senior Nurse "Preeclampsia is one of the most critical conditions you'll manage in obstetrics. Trust your assessment – if a pregnant patient tells you she has a 'bad headache,' take it deadly seriously. That headache, plus brisk reflexes, is your patient's brain screaming for help. Your quick recognition of hyperreflexia and clonus, followed by prompt action, is what stands between a controlled situation and a life-threatening eclamptic seizure. Never just 'chart and wait.' Be the nurse who acts on those subtle (and not-so-subtle) warning signs. This vigilance saves two lives."

핵심 개념

  • Preeclampsia — A hypertensive disorder of pregnancy occurring after 20 weeks gestation, characterized by new-onset hypertension and proteinuria.
  • Eclampsia — The occurrence of new-onset, generalized tonic-clonic seizures in a patient with preeclampsia, not attributable to other causes.
  • Hyperreflexia — Exaggerated deep tendon reflexes; a sign of increased central nervous system irritability, often preceding eclamptic seizures.
  • Clonus — A series of involuntary, rhythmic muscle contractions and relaxations elicited by quick dorsiflexion of the foot; a significant neurological sign of impending eclampsia.
  • Magnesium Sulfate (MgSO₄) — The drug of choice for seizure prophylaxis and treatment in preeclampsia/eclampsia. It acts as a CNS depressant and smooth muscle relaxant.

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