# 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. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540540 > language: ko > subject: Adult Health ## 문제 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. ## 보기 1. Positive Murphy's sign with inspiratory arrest **✔ 정답** 2. Rebound tenderness in the left lower quadrant 3. Cullen's sign with bluish discoloration around the umbilicus 4. Grey Turner's sign with flank discoloration **정답: 1** ## 해설 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. ## 심화 해설 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 .References (research sources) - [1]Gallbladder Perforation in a Pregnant Patient: A Case Report and Considerations of Surgical Approach.Case reportGuerra-Juarez YA, Mendez-Martinez JN, Alvarez-Lozada LA, Quiroga-Garza A, Jacobo-Baca G, Elizondo-Omaña RE. (2024) · DOI: 10.7759/cureus.73679 - [2]Management strategies for acute cholecystitis in late pregnancy: a multicenter retrospective study.Research articleZhang W, Yi H, Cai M, Zhang J. (2023) · DOI: 10.1186/s12893-023-02257-3 - [4]Management Approach to Obstructive Jaundice in Pregnancy due to Gallstones at the Milton Cato Memorial Hospital, St Vincent and the Grenadines: A Case Study.Case reportAsare ABA, Dwomoh F, Aussi B, Olarinde I, Dele DA, Joseph F, Providence S, Okyere Boadu KA. (2025) · DOI: 10.1002/ccr3.71411 ## 임상 시나리오 Assessing for Acute CholecystitisMurphy's Sign Technique and Clinical Correlation To elicit Murphy's sign, hook your fingers under the right costal margin at the RUQ and ask the patient to take a deep breath. A positive sign is an abrupt inspiratory arrest due to sharp pain as the inflamed gallbladder contacts your fingers. In pregnancy, elevated estrogen increases cholesterol in bile and progesterone slows gallbladder emptying, creating a high-risk state for gallstone formation and cholecystitis. CautionDo not confuse Murphy's sign with rebound tenderness (peritoneal sign) or hemorrhagic signs like Cullen's and Grey Turner's signs, which indicate bleeding or pancreatitis, not acute cholecystitis. ## 핵심 개념 - **Murphy's sign** — A clinical test for acute cholecystitis where RUQ palpation during deep inspiration causes sudden pain and inspiratory arrest. - **Acute Cholecystitis** — Inflammation of the gallbladder, most often caused by a gallstone obstructing the cystic duct. - **Cullen's sign** — Superficial edema and bruising around the umbilicus, indicating intra-abdominal bleeding. - **Grey Turner's sign** — Bruising of the flanks, a sign of retroperitoneal hemorrhage, classically from severe pancreatitis. ## 같은 주제 문제 - [A 47-year-old female patient presents to the emergency department with severe right upper …](https://mymerci.kr/pages/nclex_q.php?qn_id=540539) - [A 38-year-old male client is admitted to the medical-surgical unit with acute cholecystiti…](https://mymerci.kr/pages/nclex_q.php?qn_id=540541) - [A nurse is caring for a client with acute cholecystitis who is scheduled for laparoscopic …](https://mymerci.kr/pages/nclex_q.php?qn_id=540542) - [A nurse is caring for a patient with acute cholecystitis who is scheduled for laparoscopic…](https://mymerci.kr/pages/nclex_q.php?qn_id=540543) - [A nurse is caring for a client with acute cholecystitis. Which assessment finding requires…](https://mymerci.kr/pages/nclex_q.php?qn_id=540544) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._