Core Nursing Explanation
This question tests the ability to identify the most critical, life-threatening sign in a patient with severe
preeclampsia and prioritize immediate intervention. The patient's symptoms (severe headache, visual disturbances, epigastric pain) and vital signs (BP
168/110 mmHg,
3+ proteinuria) clearly indicate
Key Point! severe preeclampsia. The priority in managing severe preeclampsia is preventing progression to
eclampsia (seizures) and
HELLP syndrome (a severe complication involving hemolysis, elevated liver enzymes, and low platelets).
Answer Rationale
Key Point! The correct answer is
④ Hyperreflexia with sustained clonus. This finding is a direct sign of
central nervous system (CNS) irritability due to cerebral edema and vasospasm.
Clonus (repetitive, rhythmic jerking of the foot when the ankle is dorsiflexed) that is sustained indicates significant neurological hyperexcitability and is a
premonitory sign of an impending eclamptic seizure. Immediate administration of
magnesium sulfate is required to prevent seizures, which can lead to maternal hypoxia, brain injury, placental abruption, and fetal demise.
Distractor Analysis
- ① Ankle edema and weight gain of 2 pounds in one week: While edema and rapid weight gain can be signs of preeclampsia, they are common in normal pregnancy and are not, by themselves, indicators of an immediate, life-threatening crisis. They require monitoring but do not signal the same level of urgency as neurological signs.
- ② Decreased fetal movement reported by the patient over the past 24 hours: This is a concerning sign of possible fetal compromise and requires prompt evaluation (e.g., a non-stress test or biophysical profile). However, in the context of this scenario with severe maternal symptoms, the immediate threat to the mother's life (seizure) takes precedence. Stabilizing the mother is the first step in protecting the fetus.
- ③ Complaints of epigastric pain radiating to the right shoulder: This is a highly significant finding. Epigastric or right upper quadrant (RUQ) pain is a classic symptom of Watch out for confusion! HELLP syndrome or hepatic involvement (liver capsule distention). Pain radiating to the shoulder (Kehr's sign) suggests referred pain from diaphragmatic irritation, possibly due to hepatic hemorrhage. This finding warrants urgent evaluation and intervention. However, when compared to sustained clonus, which signals that a seizure could occur within minutes, the neurological sign is often prioritized as the most immediate concern because a seizure itself can cause catastrophic events like aspiration or abruption.
Related Concepts
The nursing priority follows the
ABCs (Airway, Breathing, Circulation) and the principle of treating the most immediate threat to life. An eclamptic seizure compromises the airway and breathing. Magnesium sulfate is the anticonvulsant of choice for preeclampsia/eclampsia, working as a central nervous system depressant and vasodilator.