# A nurse is providing prenatal education to a 28-week primigravida at a community health clinic. The nurse teaches the patient which symptoms require immediate notification of the provider or a visit to the emergency department. Which symptoms should the nurse include as obstetric warning signs? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372680&lang=en  
> language: en  
> subject: Assignment/Delegation/Supervision  
> category: HPM

## Question

A nurse is providing prenatal education to a 28-week primigravida at a community health clinic. The nurse teaches the patient which symptoms require immediate notification of the provider or a visit to the emergency department. Which symptoms should the nurse include as obstetric warning signs? Select all that apply.

1

Decreased or absent fetal movement after 28 weeks of gestation.

2

Vaginal bleeding at any point during the pregnancy.

3

Regular painful uterine contractions occurring before 37 weeks of gestation.

4

Severe persistent headache unrelieved by acetaminophen, accompanied by visual disturbances such as flashing lights or seeing spots.

5

Mild nausea and vomiting in the morning that occurs regularly during the first trimester.

6

Sudden onset of severe swelling in the face and hands that was not present upon waking.

## Explanation

After 28 weeks, decreased or absent fetal movement requires prompt evaluation (Choice 1). Vaginal bleeding at any stage of pregnancy is abnormal and needs assessment (Choice 2). Regular painful contractions before 37 weeks may indicate preterm labor (Choice 3). A severe persistent headache with visual changes can signal preeclampsia (Choice 4). Sudden marked swelling of the face and hands is also a preeclampsia warning sign (Choice 6). Mild morning nausea and vomiting during the first trimester is common and is not an emergency unless it becomes severe, causes dehydration or weight loss, or is accompanied by other concerning findings (Choice 5).

## In-depth explanation

Clinical Judgment
The key to this question is distinguishing normal discomforts of pregnancy from true danger signs. Option 3 (mild morning nausea) is the only expected discomfort. The five warning signs span all three trimesters and major obstetric emergencies:
1st Tri: Any vaginal bleeding → ectopic/miscarriage
2nd/3rd Tri: Headache + visual changes → preeclampsia | Sudden face/hand edema → preeclampsia
After 28 wks: Decreased fetal movement → fetal distress
Before 37 wks: Regular contractions → preterm labor

Memory Tip
OBWARN: Oozing/Bleeding any time + Blurry vision/headache + Warning: swelling face-hands + Absent fetal movement + Regular contractions <37wks + Nausea mild 1st tri = NORMAL

KR vs US
Kick count methods vary: Cardiff (count 10 movements within 2 hours) vs Sadovsky (count movements 1 hour after meals). US ACOG recommends patient-defined change in usual movement pattern as the primary concern, not a strict count threshold. In Korea, kick counts are taught but thresholds may differ by hospital protocol.

## Clinical scenario

Clinical Practice Guide
Preeclampsia Warning Signs (ACOG): Severe persistent headache + visual disturbances; sudden severe facial/hand edema; epigastric or RUQ pain (HELLP syndrome); BP ≥160/110 on two occasions ≥4 h apart; proteinuria ≥0.3 g/24 h. After 20 weeks gestation.

Vaginal Bleeding by Trimester: 1st — threatened/inevitable/complete/missed abortion, ectopic pregnancy; 2nd — cervical incompetence, placenta previa, subchorionic hematoma; 3rd — placenta previa (painless), placental abruption (painful), bloody show (normal near term).

Fetal Movement Monitoring: Kick counts begin at 28 weeks. Cardiff method: 10 movements in ≤2 hours. Decreased movement — perform NST within 2 hours; if nonreactive, proceed to BPP or contraction stress test (CST).

## Key concepts

- **Preeclampsia / 전자간증 — 임신 고혈압 장애 (20주 이후)** — Preeclampsia definition (ACOG): New-onset hypertension (>=140/90 mmHg) after 20 weeks with proteinuria or severe features (headache, visual changes, epigastric pain, thrombocytopenia, renal/liver dysfunction). Risk of progression to eclampsia (seizures), HELLP syndrome, and maternal/fetal death.
- **Preterm Labor / 조산 — 37주 이전 규칙적 수축** — Preterm labor: regular uterine contractions (>=4 in 20 min or >=8 in 60 min) causing cervical change before 37 weeks. Management: tocolytics (nifedipine, indomethacin), antenatal corticosteroids (betamethasone 12 mg IM x2 for fetal lung maturity at 24-34 weeks), GBS prophylaxis if positive, magnesium sulfate for neuroprotection if <32 weeks.
- **Kick Count / 태동 수 — 28주 이후 태아 안녕 모니터링** — Kick count monitoring: after 28 weeks, the fetus should move at least 10 times in 2 hours (Cardiff method) or show habitual movement patterns. Decreased fetal movement is the leading symptom preceding intrauterine fetal demise (IUFD). Immediate NST; if nonreactive, BPP within 24 hours.

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