# 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? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542831 > language: ko > subject: Maternal Newborn Health ## 문제 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? ## 보기 1. Blood pressure of 150/95 mmHg with 2+ proteinuria and facial edema **✔ 정답** 2. Fundal height measuring 22 cm at 24 weeks gestation 3. Fetal heart rate of 150 beats per minute with good variability 4. Weight gain of 12 pounds since the beginning of pregnancy **정답: 1** ## 해설 Blood pressure 150/95 mmHg with proteinuria and facial edema indicates preeclampsia requiring immediate evaluation. Other findings are normal or expected in pregnancy. ## 심화 해설 Clinical Presentation Analysis A 28-year-old primigravida at 24 weeks gestation presents with a blood pressure of 150/95 mmHg, 2+ proteinuria, and facial edema. This triad represents the classic clinical presentation of preeclampsia, a hypertensive disorder of pregnancy that can progress rapidly and threaten both maternal and fetal well-being [4]. Why This Finding Is Most Concerning The combination of new-onset hypertension after 20 weeks gestation with proteinuria and edema directly aligns with the diagnostic criteria for preeclampsia. Historically, the triad of blood pressure measurement, urinalysis, and edema assessment has been the cornerstone of prenatal care specifically because it enables early detection of hypertensive disorders of pregnancy, which were once a leading cause of maternal mortality [4]. At 24 weeks, this presentation is particularly dangerous because early-onset preeclampsia tends to be more severe and carries higher risks of progression to eclampsia, HELLP syndrome, placental abruption, and fetal growth restriction. The pathophysiology involves systemic endothelial dysfunction and vasospasm. When proteinuria reaches 2+ on dipstick, it indicates significant glomerular endothelial injury. A study of 319 women with isolated gestational proteinuria demonstrated that proteinuria of 300 mg/day or greater after 20 weeks can represent an early stage in the spectrum of preeclampsia, and some patients progress to develop the full syndrome [2]. The concurrent elevation in blood pressure to 150/95 mmHg confirms that this is no longer isolated proteinuria but established preeclampsia requiring immediate intervention. Differential Considerations and Severity Assessment When proteinuria is present in pregnancy, clinicians must also consider whether a primary renal pathology exists. A case report highlighted that focal and segmental glomerulosclerosis (FSGS) can present with nephrotic-range proteinuria during pregnancy and mimic preeclampsia [3]. However, the presence of concurrent hypertension and facial edema in this patient makes preeclampsia far more likely than an isolated glomerular disease. The use of angiogenic biomarkers such as the sFlt-1/PlGF ratio can help differentiate preeclampsia from other proteinuric conditions when the presentation is atypical, but in this classic presentation, immediate clinical action based on blood pressure and urine findings takes priority [3]. The severity is underscored by research on nephrotic syndrome during pregnancy, where patients with moderate to severe preeclampsia who develop significant proteinuria require aggressive management. In a retrospective study of 314 women, those with nephrotic syndrome during pregnancy received protein-supportive therapy including supplemental human albumin in addition to blood pressure control, reflecting the seriousness of massive protein loss . While this patient has not yet reached nephrotic-range proteinuria, the presence of 2+ proteinuria with hypertension signals a trajectory that demands immediate hospitalization, seizure prophylaxis assessment, blood pressure management, and fetal surveillance. Analysis of Other Options Fundal height measuring 22 cm at 24 weeks gestation represents a normal finding, as fundal height in centimeters typically correlates with weeks of gestation between 20 and 34 weeks, with a variance of plus or minus 2 cm considered acceptable. A fetal heart rate of 150 beats per minute with good variability is a reassuring sign of fetal well-being and normal autonomic nervous system development. Weight gain of 12 pounds by 24 weeks falls within the recommended range for a woman with a normal pre-pregnancy body mass index, where total weight gain of 25 to 35 pounds is expected. None of these findings indicate acute pathology requiring immediate intervention, whereas the elevated blood pressure with proteinuria and edema represents a potentially life-threatening condition that can deteriorate rapidly without prompt evaluation and management [4].References (research sources) - [2]Limited Predictive Value of Inflammatory and Renal Markers in the Progression of Isolated Gestational Proteinuria to Preeclampsia: A Retrospective Cohort Study.Research articleSümer D, Filiz AA, Yıldırım P, Bayraktar A, Aslanlı İ, Göksu A, Çanga K, Vural Yılmaz Z. (2026) · DOI: 10.3390/jcm15103966 - [3]Beyond Preeclampsia: Focal and Segmental Glomerulosclerosis Presenting as Nephrotic-Range Proteinuria During Pregnancy, A Clinical Case Report.Case reportXimena Rosario SA, Eva Elizabet CP. (2026) · DOI: 10.1002/ccr3.72496 - [4]Blood Pressure, Urinalysis, and Edema Assessment in Perinatal Care: From Historical Foundations to Evidence-Based Practice.Research articleChigusa Y, Yamano K, Miyamoto T, Mogami H, Mandai M, Metoki H, Sekizawa A. (2026) · DOI: 10.31662/jmaj.2025-0241 ## 임상 시나리오 Clinical Practice Guide: Immediate Response to Suspected Preeclampsia 1. Immediate Actions - Obtain a full set of maternal vital signs, including a repeat blood pressure measurement after 15 minutes of rest in a left lateral recumbent position. - Assess deep tendon reflexes and check for clonus to evaluate central nervous system irritability. - Perform a focused physical assessment for generalized edema, right upper quadrant or epigastric pain, severe headache, and visual disturbances. - Notify the obstetrical provider immediately with a concise SBAR report highlighting the hypertensive crisis and proteinuria. 2. Diagnostic Workup - Send stat laboratory tests: complete blood count (CBC) to assess for thrombocytopenia, liver function tests (LFTs) for elevated transaminases, serum creatinine, and uric acid. - Collect a 24-hour urine sample or a spot urine protein-to-creatinine ratio to quantify proteinuria (threshold: 300 mg or more in 24 hours). - Initiate continuous fetal heart rate monitoring and assess for late decelerations, minimal variability, or bradycardia. - Perform an obstetrical ultrasound to evaluate fetal growth, amniotic fluid volume, and biophysical profile. 3. Management Priorities - Administer antihypertensive therapy as ordered for severe hypertension (systolic BP 160 mmHg or higher or diastolic BP 110 mmHg or higher) to prevent maternal stroke while maintaining placental perfusion. - Administer magnesium sulfate for seizure prophylaxis in patients with severe features, following institutional protocol for loading and maintenance doses. - Prepare for possible preterm delivery if maternal or fetal status deteriorates; administer antenatal corticosteroids for fetal lung maturity if gestational age is less than 34 weeks. - Maintain strict intake and output monitoring, and limit intravenous fluids to reduce the risk of pulmonary edema. 4. Ongoing Monitoring and Patient Education - Monitor vital signs, reflexes, and oxygen saturation at least every hour; auscultate lung sounds for crackles indicating pulmonary edema. - Educate the patient on the warning signs of worsening preeclampsia, including severe headache, vision changes, and decreased fetal movement, and instruct her to report them immediately. - Implement seizure precautions: padded side rails, suction equipment and oxygen at bedside, and a quiet, dimly lit environment. ## 핵심 개념 - **Preeclampsia** — A pregnancy-specific hypertensive disorder with new-onset hypertension and proteinuria after 20 weeks gestation, potentially leading to serious maternal and fetal complications. - **Proteinuria** — Excess protein in the urine, indicated by 2+ on dipstick, signifying glomerular endothelial injury and a key diagnostic criterion for preeclampsia. - **Fundal Height** — The distance from the pubic bone to the top of the uterus, measured in centimeters, which typically corresponds to gestational age between 20-34 weeks. - **Primigravida** — A woman who is pregnant for the first time. ## 같은 주제 문제 - [A 28-year-old primigravida at 32 weeks gestation presents for a routine prenatal visit. 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