A 28-year-old primigravida at 34 weeks gestation presents to… | 마이메르시 MyMerci
Maternal Newborn Health
문제

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?

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.

심화 해설

Core Nursing Explanation This question tests the critical nursing skill of prioritizing assessment findings in a patient with severe preeclampsia, moving toward eclampsia. The core concept is recognizing which sign indicates the most immediate, life-threatening risk: eclamptic seizure. Key Concept Analysis The patient presents with classic symptoms of severe preeclampsia: severe headache, visual disturbances, epigastric pain (suggesting liver capsule distention), severe hypertension (168/110 mmHg), and significant proteinuria (3+). The pathophysiological mechanism involves widespread vasospasm and endothelial dysfunction, leading to hypertension, proteinuria, and reduced organ perfusion. The brain is particularly vulnerable; cerebral vasospasm and edema increase the risk of seizures. Answer Rationale Key Point! Hyperreflexia with sustained clonus is a direct sign of severe central nervous system (CNS) irritability. Clonus is a series of involuntary, rhythmic muscle contractions and relaxations. When it is sustained (lasting more than 3 seconds), it indicates a significant lowering of the seizure threshold. This finding is a premonitory sign that an eclamptic seizure may occur imminently, within minutes to hours. This requires the most urgent intervention: immediate administration of magnesium sulfate (the anticonvulsant of choice) and implementation of seizure precautions to protect the mother and fetus. Distractor Analysis ① Decreased fetal movement: This is a serious finding indicating possible fetal compromise (e.g., uteroplacental insufficiency) and requires prompt evaluation (e.g., a non-stress test). However, the most immediate threat to both the mother and fetus is the mother's impending seizure, which can cause abruptio placentae, fetal bradycardia, and maternal hypoxia.
② Blood pressure of 170/112 mmHg: While this confirms severe hypertension and requires antihypertensive medication (e.g., labetalol, hydralazine), the primary goal of antihypertensive therapy in preeclampsia is to prevent maternal stroke, not to treat the underlying disease process causing seizures. Magnesium sulfate is given for seizure prophylaxis regardless of the specific BP number once severe features are present.
③ Blurred vision and "spots": These visual disturbances are classic symptoms caused by retinal arteriolar vasospasm or cerebral edema affecting the occipital lobe. They are a Watch out for confusion! "red flag" symptom that qualifies the preeclampsia as "severe," but they represent a symptom of the disease process, not the specific neurological hyperexcitability that heralds an immediate seizure. Related Concepts The progression from preeclampsia to eclampsia is defined by the onset of seizures. Nursing priorities shift to airway protection, preventing injury, and preparing for delivery, which is the definitive treatment. The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe variant often associated with epigastric/RUQ pain.
Concept Summary
TermDefinition & Significance
PreeclampsiaHypertension (≥140/90 mmHg) with proteinuria after 20 weeks gestation. "Severe" features include BP ≥160/110, cerebral/visual symptoms, epigastric pain, pulmonary edema, impaired liver/renal function, thrombocytopenia.
EclampsiaThe occurrence of new-onset, generalized tonic-clonic seizures in a patient with preeclampsia, not attributable to other causes. A medical emergency.
Hyperreflexia & ClonusSigns of CNS irritability. Sustained clonus is a key premonitory sign of imminent eclampsia.
Magnesium SulfateFirst-line anticonvulsant for seizure prophylaxis and treatment in preeclampsia/eclampsia. Therapeutic level: 4-7 mg/dL. Toxicity signs: loss of deep tendon reflexes (DTRs)

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a labor and delivery unit. Ms. Jones, a 28-year-old G1P0 at 34 weeks, is admitted with a BP of 168/110, 3+ proteinuria, and complaints of a "crushing" headache and spots in her vision. You are performing your initial assessment. Nursing Intervention Strategy: 1. Assessment & Safety: * Immediate: Perform a thorough neurological assessment. Check deep tendon reflexes (DTRs) at the patella and biceps. Assess for clonus by quickly dorsiflexing the foot—count how many beats occur before it stops. Sustained (>3 sec) is critical. * Vitals & Monitoring: Place on continuous fetal heart rate (FHR) and contraction (toco) monitoring. Obtain IV access with a large-bore catheter. Strict I&O (catheterize for accuracy). Monitor for worsening symptoms (increased headache, new pain). * Environment: Institute seizure precautions: pad side rails, have suction and oxygen ready at bedside, keep the room quiet and dimly lit. 2. Implementation & Collaboration: * Medication Administration: Anticipate orders for MgSO4 loading dose (4-6 g IV over 15-20 min) followed by a maintenance infusion (1-2 g/hr). Double-check the pump settings and label the line clearly. Simultaneously, antihypertensives (e.g., labetalol) will be given to lower BP. * Communication: Notify the provider immediately of the clonus finding. Collaborate with the neonatal team for potential preterm delivery. 3. Evaluation & Patient Education: * Evaluate Therapy: Monitor for therapeutic effect (resolution of clonus, no seizure activity) and toxicity (check DTRs hourly, monitor respiratory rate and urine output). * Educate: Explain all procedures and the purpose of MgSO4 to the patient and support person. Teach them to report any new symptoms immediately. Patient Safety and Precautions * MgSO4 Administration: Never bolus rapidly. Use an infusion pump. Have calcium gluconate (10 mL of 10% solution) at the bedside as the antidote. * During a Seizure: Do not restrain. Turn patient to left lateral position to prevent aspiration and improve uteroplacental blood flow. Administer oxygen. Time the seizure. Afterward, assess fetal heart rate and maternal status. * Contraindications/Cautions: MgSO4 is used with caution in patients with renal impairment (excreted by kidneys). Monitor serum Mg levels if infusion continues >24 hours.
Nursing Procedure & Medication Flow Procedure: Administering Magnesium Sulfate for Seizure Prophylaxis 1. Verify order: Loading dose (e.g., 4 g IV in 100 mL NS over 20 min) and maintenance dose (e.g., 1 g/hr IV). 2. Assess baseline: Neurological status (DTRs, clonus), respiratory rate (>12/min), urine output (>30 mL/hr). 3. Prepare medication: Use premixed bag or dilute per protocol. Label line clearly: "MAGNESIUM SULFATE – FOR SEIZURE PROPHYLAXIS". 4. Administer loading dose via infusion pump over ordered time (15-20 min). Observe for flushing, warmth, transient hypotension. 5. Initiate maintenance infusion via pump at ordered rate. 6. Monitor: DTRs and respiratory rate hourly. Strict I&O. Assess for signs of toxicity (loss of DTRs, respiratory depression, slurred speech). 7. If toxicity suspected: STOP infusion, notify provider, prepare to administer calcium gluconate IV slowly, support airway.
A Word from Your Senior Nurse "Nursing in obstetrics is about guarding two lives simultaneously. With preeclampsia, your sharp assessment skills are the early warning system. That patellar reflex you check isn't just a routine task—it's a direct window into her brain's irritability. When you feel that sustained clonus, your heart might race, but your training kicks in. You know that administering that magnesium sulfate isn't just 'following an order'; you are actively preventing a seizure that could cause placental abruption, fetal distress, and maternal trauma. On the NCLEX, they are testing if you understand the 'why' behind the priority. In real life, that understanding saves lives. Always connect the pathophysiology (vasospasm → CNS irritability) to the sign (clonus) to the action (MgSO4). That's what makes a great nurse."

핵심 개념

  • Preeclampsia — A pregnancy-specific syndrome of hypertension (≥140/90 mmHg) occurring after 20 weeks of gestation with proteinuria (≥300 mg/24hrs or 1+ dipstick). It involves systemic endothelial dysfunction and vasospasm.
  • Eclampsia — The occurrence of new-onset, generalized tonic-clonic seizures in a patient with preeclampsia, not attributable to other cerebral conditions. It is a life-threatening obstetric emergency.
  • Clonus — A series of involuntary, rhythmic, muscular contractions and relaxations, typically elicited by rapid dorsiflexion of the foot. Sustained clonus (lasting >3 seconds) is a sign of severe neurological hyperexcitability and a premonitory sign of imminent eclampsia.
  • Magnesium Sulfate — The first-line anticonvulsant medication used for the prevention and treatment of seizures in preeclampsia and eclampsia. It acts as a CNS depressant and peripheral vasodilator. Therapeutic serum level is 4-7 mg/dL.
  • HELLP Syndrome — A severe, life-threatening variant of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. It often presents with epigastric or right upper quadrant pain, nausea, and malaise.

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