A nurse is assessing a 28-year-old pregnant client who presents to the emergency department with severe right upper quadrant pain and nausea. The client reports a history of gallstones and the pain has been intermittent for the past 2 days.

Murphy's sign is the most specific assessment for acute cholecystitis, involving inspiratory arrest on palpation. Other signs are indicative of different conditions like diverticulitis, pancreatitis, or appendicitis.

Correct Answer Analysis

The correct answer is Positive Murphy's sign with inspiratory arrest. This is the classic clinical finding associated with acute cholecystitis, which is inflammation of the gallbladder most commonly caused by an obstructing gallstone in the cystic duct. The assessment technique involves the examiner palpating the right upper quadrant (RUQ) at the costal margin while the patient takes a deep breath. As the inflamed gallbladder descends and contacts the examiner's fingers, the patient experiences a sudden, sharp increase in pain and abruptly stops inspiration. This finding is highly specific for acute gallbladder inflammation.

In the context of pregnancy, the physiological changes of gestation significantly increase the risk for biliary pathology. Elevated estrogen levels lead to increased cholesterol saturation in bile, while progesterone induces smooth muscle relaxation, resulting in biliary stasis and delayed gallbladder emptying. These hormone-induced changes create a lithogenic environment, making gallstone formation and subsequent complications such as acute cholecystitis more common during pregnancy ^[4]. The provided case report on gallbladder perforation explicitly notes that gallbladder disease is a frequent indication for non-obstetric surgical intervention during pregnancy, underscoring the clinical relevance of this assessment finding ^[1]. A multicenter study on management strategies further confirms that acute cholecystitis in pregnancy requires prompt recognition to guide timely intervention and prevent maternal-fetal complications ^[2].

Incorrect Answer Analysis

Rebound tenderness in the left lower quadrant (Option 2) is incorrect. Rebound tenderness is a sign of peritoneal irritation, and when localized to the left lower quadrant, it is classically associated with conditions such as diverticulitis or a ruptured ectopic pregnancy with blood tracking to that area. It does not correspond to the right upper quadrant pathology of the biliary system described in the client's presentation.

Cullen's sign with bluish discoloration around the umbilicus (Option 3) and Grey Turner's sign with flank discoloration (Option 4) are both incorrect. These are late, non-specific signs of retroperitoneal hemorrhage, most commonly associated with severe hemorrhagic pancreatitis or a ruptured abdominal aortic aneurysm. They represent the tracking of blood along fascial planes to the periumbilical area (Cullen's) or the flanks (Grey Turner's). While gallstones can migrate and cause pancreatitis, the client's presenting symptoms of severe, intermittent RUQ pain with a history of gallstones point directly to an acute gallbladder process, not a hemorrhagic pancreatic complication. The case report on choledocholithiasis in pregnancy highlights that while stone migration can lead to complex conditions like obstructive jaundice or pancreatitis, the initial and most direct assessment finding for gallbladder inflammation itself remains the Murphy's sign .