Core Nursing Explanation
Key Concept Analysis: This question assesses the nurse's ability to identify a potentially life-threatening complication of pregnancy during a routine prenatal visit. The core theme is recognizing the classic signs of
Preeclampsia, a hypertensive disorder unique to pregnancy. Preeclampsia is defined by new-onset hypertension (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg)
and proteinuria (≥300 mg/24-hour urine or ≥1+ on dipstick) after 20 weeks of gestation in a previously normotensive woman. It can progress rapidly to severe preeclampsia or
Eclampsia (seizures), posing significant risks to both mother and fetus.
Answer Rationale:
Key Point! A blood pressure of
150/95 mmHg with
2+ proteinuria and
Facial edema is the triad of classic signs for preeclampsia. This finding is the most concerning because it indicates a systemic disorder affecting the vascular endothelium, which can lead to complications like placental abruption, HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), cerebral hemorrhage, and fetal growth restriction. This requires
immediate further evaluation, which would include a 24-hour urine collection for total protein, liver function tests (LFTs), complete blood count (CBC) with platelet count, and likely hospitalization for monitoring and management.
Distractor Analysis:
Watch out for confusion! Option ②: A fundal height of 22 cm at 24 weeks gestation is
within the normal range (fundal height in cm roughly equals gestational age in weeks ± 2 cm). This finding alone is not concerning.
Option ③: A fetal heart rate (FHR) of 150 bpm with good variability is a
reassuring sign of fetal well-being. The normal FHR range is 110-160 bpm.
Option ④: A weight gain of 12 pounds (approx. 5.4 kg) since the beginning of pregnancy is appropriate for 24 weeks. The recommended total weight gain for a primigravida with a normal pre-pregnancy BMI is 25-35 pounds (11.5-16 kg).
Related Concepts: It is crucial to differentiate preeclampsia from chronic hypertension and gestational hypertension. The presence of proteinuria is the key differentiator for preeclampsia. Nursing priorities for a patient with suspected preeclampsia include frequent blood pressure monitoring, assessing for signs of severe features (headache, visual changes, epigastric pain), monitoring fetal status, and preparing for possible magnesium sulfate administration for seizure prophylaxis.
Concept Summary
Preeclampsia: Hypertension + Proteinuria after 20 weeks gestation.
Severe Features: BP ≥160/110, severe headache, visual disturbances, epigastric/RUQ pain, pulmonary edema, thrombocytopenia, impaired liver function.
HELLP Syndrome: A severe variant (Hemolysis, Elevated Liver enzymes, Low Platelets).
Definitive Treatment: Delivery of the fetus and placenta.
Nursing Focus: Seizure prevention (MgSO4), blood pressure control, fetal monitoring, patient education on danger signs.
Side-by-Side Comparison!
| Assessment Finding | Interpretation at 24 Weeks | Nursing Action |
|---|
| BP 150/95, 2+ proteinuria, edema | Key Point! Preeclampsia - Requires immediate evaluation. | Notify provider STAT. Admit for monitoring. Prepare for labs (CBC, LFTs, 24-hr urine). |
| Fundal height 22 cm | Normal variation (22-26 cm expected). | Document as a normal finding. Continue routine prenatal care. |
| FHR 150 bpm, good variability | Reassuring fetal status. | Document. No immediate action needed. |
| Weight gain 12 lbs | Appropriate gain (~0.5 lb/week). | Reinforce healthy nutrition. No cause for concern. |
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Preeclampsia involves abnormal placental development leading to widespread maternal endothelial dysfunction, vasospasm, and increased vascular permeability. This causes hypertension, proteinuria, and edema.
Key Drug:
Magnesium sulfate is the drug of choice for preventing and treating eclamptic seizures. It is a central nervous system depressant. Nurses must monitor for toxicity: loss of deep tendon reflexes (DTRs) is an early sign, followed by respiratory depression and cardiac arrest. Calcium gluconate is the antidote.
Antihypertensives: Labetalol or hydralazine may be used for severe hypertension.
Memory Tips
Mnemonic for Preeclampsia Symptoms:
HELP
Headache (severe)
Epigastric pain /
Edema (sudden, facial/hands)
Liver enzymes elevated
Proteinuria /
Platelets low
Remember: The patient and fetus need "
HELP" immediately!
High-Frequency NCLEX Topics
Preeclampsia is a
must-know topic for the NCLEX-RN. Expect questions on:
1. Identifying signs and symptoms from a scenario.
2. Prioritizing nursing actions (e.g., "Which finding should the nurse report immediately?").
3. Understanding medication administration and monitoring for MgSO4.
4. Knowing patient education topics (report headache, visual changes, epigastric pain).
Watch Out for Question Variations!
The same concept can be tested in many ways:
From Assessment to Intervention: "The nurse identifies the above findings in a prenatal client. What is the
priority nursing action?" (Answer: Notify the healthcare provider immediately).
From Signs to Complications: "A client with preeclampsia reports severe headache and blurred vision. The nurse should be alert for which complication?" (Answer: Eclampsia/seizure).
Medication Focus: "A client receiving magnesium sulfate has absent patellar reflexes. What is the nurse's priority action?" (Answer: Stop the magnesium infusion and notify the provider).