A 28-year-old primigravida at 24 weeks gestation presents for a routine prenatal visit. Which assessment finding would be most concerning and require immediate further evaluation?
1Blood pressure of 150/95 mmHg with 2+ proteinuria and facial edema✓ 정답
2Fundal height measuring 22 cm at 24 weeks gestation
3Fetal heart rate of 150 beats per minute with good variability
4Weight gain of 12 pounds since the beginning of pregnancy
해설
Blood pressure 150/95 mmHg with proteinuria and facial edema indicates preeclampsia requiring immediate evaluation. Other findings are normal or expected in pregnancy.
Core Nursing ExplanationKey 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!
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).
Nursing Clinical Practice GuideClinical Scenario: You are a nurse in a prenatal clinic. Maria, a 28-year-old first-time mother at 24 weeks, comes for her check-up. She mentions her rings feel tight and her face looks a bit puffy this morning. During your assessment, her BP is 150/95 (her baseline has been around 110/70), and a urine dipstick shows 2+ protein.Nursing Intervention Strategy:
1Immediate Assessment & SafetyKeep the patient in a quiet room, left lateral recumbent position to improve placental perfusion. Re-check BP in 15 minutes after rest. Perform a focused neurological assessment: ask about headache, visual changes (scotomata), and epigastric pain.
2Communication & CollaborationNotify the obstetric provider or midwife immediately with your findings. Do not dismiss this as "just swelling."
3Diagnostic CoordinationAnticipate orders for stat labs (CBC, LFTs, creatinine) and instructions for a 24-hour urine collection. Explain the procedures to the patient calmly.
4Monitoring & PreparationContinuous fetal heart rate monitoring may be initiated. Be prepared for the possibility of hospital admission. If severe features are present, prepare for transfer to labor and delivery.
Patient Safety and Precautions:
- Key Point! Never send a patient with suspected preeclampsia home without a thorough evaluation by a provider. The condition can deteriorate rapidly.
- Educate the patient on danger signs to report immediately: severe headache, visual changes, upper abdominal pain, shortness of breath, or decreased fetal movement.
- In the hospital setting, for patients on magnesium sulfate, strict intake and output (I&O) monitoring is essential, along with hourly assessment of DTRs, respiratory rate, and level of consciousness.
Nursing Procedure & Medication FlowFor Suspected Preeclampsia in Clinic:
1. Accurate BP measurement with correct cuff size, patient seated.
2. Clean-catch urine specimen for protein analysis.
3. Documentation of edema (scale 1+ to 4+ and location).
4. Patient education on danger signs using clear, simple language.For Magnesium Sulfate Administration (Inpatient):
1Loading DoseTypically 4-6 g IV over 20-30 minutes.
2Maintenance Dose1-2 g/hour via infusion pump.
3Nursing Monitoring (Q1H)
Deep Tendon Reflexes (DTRs)Absent reflexes = first sign of toxicity.
Respiratory RateMust be >12 breaths/min.
Urine OutputMust be >30 mL/hr (Mg is renally excreted).
Level of Consciousness.
4Antidote at BedsideCalcium gluconate 1 g (10 mL of 10% solution) for IV push in case of life-threatening toxicity.
A Word from Your Senior Nurse
"Trust your assessment skills! In prenatal care, you are the first line of defense for catching conditions like preeclampsia early. That 'gut feeling' when a patient's BP is up and she has new swelling is often your nursing knowledge speaking. Never hesitate to double-check or escalate your concerns. Catching preeclampsia early and managing it proactively can literally save two lives. When you study this, don't just memorize the numbers 140/90 and proteinuria. Picture your patient, see her swollen face, hear her mention the headache, and connect that to the pathophysiology happening inside her body. That connection is what makes you an excellent nurse, not just a good test-taker."
Preeclampsia — A hypertensive disorder of pregnancy characterized by new-onset hypertension (≥140/90 mmHg) and proteinuria (≥300 mg/24hr) after 20 weeks of gestation.
Proteinuria — The presence of an excess of serum proteins in the urine. In pregnancy, significant proteinuria (≥1+ on dipstick or ≥300 mg/24hr) is a key diagnostic criterion for preeclampsia.
Fundal Height — The distance from the top of the mother's pubic bone (symphysis pubis) to the top of the uterus (fundus). Measured in centimeters, it is used to estimate gestational age and fetal growth (should roughly equal weeks of gestation ± 2 cm).
Magnesium Sulfate — A medication used in obstetrics as a first-line agent for the prevention and treatment of seizures in women with preeclampsia or eclampsia. It is a central nervous system depressant, and nurses must monitor closely for signs of toxicity.
HELLP Syndrome — A severe, life-threatening variant of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. It represents a medical emergency.