# A 28-year-old pregnant woman at 32 weeks gestation presents to the prenatal clinic with complaints of severe headaches, visual disturbances, and upper abdominal pain. Her blood pressure is 168/110 mmHg, and she has 3+ proteinuria. Which assessment finding would be MOST concerning and require immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542839 > language: ko > subject: Maternal Newborn Health ## 문제 A 28-year-old pregnant woman at 32 weeks gestation presents to the prenatal clinic with complaints of severe headaches, visual disturbances, and upper abdominal pain. Her blood pressure is 168/110 mmHg, and she has 3+ proteinuria. Which assessment finding would be MOST concerning and require immediate intervention? ## 보기 1. Ankle edema and weight gain of 2 pounds in one week 2. Decreased fetal movement reported by the patient over the past 24 hours 3. Complaints of epigastric pain radiating to the right shoulder 4. Hyperreflexia with sustained clonus **✔ 정답** **정답: 4** ## 해설 Hyperreflexia with sustained clonus indicates severe CNS irritability and imminent risk of eclamptic seizures, requiring immediate magnesium sulfate. Other findings like edema or decreased fetal movement are concerning but less urgent. ## 심화 해설 Clinical Context and Priority Setting This patient presents with classic findings of severe preeclampsia at 32 weeks gestation: severe-range hypertension (168/110 mmHg), significant proteinuria (3+), severe headache, visual disturbances, and upper abdominal pain. In the NCLEX-RN framework, this scenario falls under the Physiological Integrity category, specifically Reduction of Risk Potential. The question tests the ability to recognize the most ominous sign indicating impending eclampsia, a life-threatening progression of preeclampsia. The principle of prioritization here is based on the ABCs (Airway, Breathing, Circulation) and the risk for immediate maternal seizure, which compromises the airway and oxygenation for both mother and fetus. Analysis of Findings and Rationale for Correct Answer The correct answer is hyperreflexia with sustained clonus. This finding represents severe central nervous system (CNS) irritability and is a direct precursor to a generalized tonic-clonic seizure, the defining event of eclampsia. The pathophysiology involves cerebral vasospasm, endothelial dysfunction, and loss of cerebral autoregulation from severe hypertension, leading to cerebral edema and neuronal hyperexcitability. Sustained clonus indicates that the neuromuscular junction is in a state of extreme hyperstimulation, and without immediate intervention, a seizure is imminent. The standard of care for seizure prophylaxis and treatment in this context is magnesium sulfate, which acts as a CNS depressant by competing with calcium at the motor end plate and within the central nervous system, thereby stabilizing neuronal membranes [2]. The urgency is underscored by evidence confirming magnesium sulfate as a cornerstone therapy for preventing the progression from severe preeclampsia to eclampsia [2, 3]. Why Other Options Are Less Concerning Option 1: Ankle edema and a weight gain of 2 pounds in one week are common findings in normal pregnancy and non-severe preeclampsia. While they indicate fluid retention and are part of the clinical picture, they do not represent an immediate threat to life or signal an impending catastrophic event like a seizure. This finding requires continued monitoring but not the most urgent intervention. Option 2: Decreased fetal movement reported over 24 hours is a highly concerning sign for fetal well-being and may indicate uteroplacental insufficiency, a known complication of severe preeclampsia. A case report highlights that reduced fetal movements in a patient with severe preeclampsia necessitated emergency cesarean delivery due to worsening disease and oligohydramnios . However, in the hierarchy of maternal-fetal prioritization, the maternal condition takes precedence because a maternal seizure leads to hypoxia and bradycardia, which will rapidly and profoundly compromise the fetus. Stabilizing the mother is the first step in stabilizing the fetus. Option 3: Epigastric pain radiating to the right shoulder is a classic sign of liver capsule distension or subcapsular hematoma, often associated with HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), a severe variant of preeclampsia . This finding indicates significant hepatic involvement and risk for life-threatening rupture. While extremely serious and requiring immediate diagnostic evaluation and management, it does not carry the same second-to-minutes imminence of respiratory arrest and hypoxic injury as a seizure triggered by CNS hyperexcitability. Seizure activity will immediately obstruct the airway, making hyperreflexia with clonus the most time-critical finding to address.References (research sources) - [2]Magnesium sulfate pharmacology for maternal and critical-care indications: mechanisms, pharmacokinetics, and the therapeutic window.Research articleXia M, Ni Q, Zhu S. (2026) · DOI: 10.3389/fphar.2026.1749828 ## 임상 시나리오 Clinical Management of Severe Preeclampsia with CNS Irritability Upon identifying hyperreflexia with sustained clonus in a patient with severe preeclampsia, immediate action is required to prevent eclamptic seizure. The cornerstone of management is the administration of magnesium sulfate. Immediate Interventions - **Seizure Prophylaxis:** Administer IV magnesium sulfate per facility protocol (commonly a 4-6 g loading dose over 15-20 minutes, followed by a maintenance infusion of 1-2 g/hour). Therapeutic serum magnesium levels are typically 4-7 mEq/L. - **Seizure Precautions:** Pad the side rails of the bed, ensure suction equipment and oxygen are at the bedside, and maintain a patent airway. Keep the bed in the lowest position. - **Blood Pressure Control:** Administer antihypertensive agents (e.g., IV labetalol or hydralazine) to lower blood pressure to a safe range (typically 140-150/90-100 mmHg) to reduce the risk of hemorrhagic stroke without compromising placental perfusion. - **Maternal-Fetal Monitoring:** Initiate continuous electronic fetal monitoring and frequent maternal vital sign and neurological assessments, including deep tendon reflexes and respiratory rate. Ongoing Assessment and Safety - **Magnesium Toxicity Monitoring:** Assess for signs of toxicity before each dose, including loss of deep tendon reflexes (first sign), respiratory depression (rate < 12/min), and decreased urine output (< 30 mL/hr). Keep calcium gluconate readily available as the antidote. - **Delivery Planning:** Severe preeclampsia at 32 weeks necessitates immediate consultation with obstetrics and neonatology. Corticosteroids (betamethasone) should be administered for fetal lung maturity if delivery is not immediately indicated. Definitive treatment is delivery of the placenta. - **Environmental Control:** Minimize external stimuli by maintaining a quiet, dimly lit room to reduce the risk of triggering a seizure. This guidance reflects standard obstetric emergency protocols for severe preeclampsia with CNS involvement. Always follow institutional policies and consult maternal-fetal medicine specialists. ## 핵심 개념 - **Clonus** — A series of involuntary, rhythmic, muscular contractions and relaxations; sustained clonus indicates severe central nervous system hyperexcitability. - **Eclampsia** — The onset of generalized tonic-clonic seizures in a woman with preeclampsia, a life-threatening obstetric emergency. - **Preeclampsia** — A pregnancy-specific hypertensive disorder characterized by new-onset hypertension and proteinuria or end-organ dysfunction after 20 weeks gestation. - **Magnesium Sulfate** — The first-line agent for seizure prophylaxis and treatment in severe preeclampsia and eclampsia, acting as a central nervous system depressant. - **Cerebral Autoregulation** — The brain's ability to maintain constant blood flow despite changes in systemic blood pressure; lost in severe preeclampsia, leading to edema and hyperexcitability. ## 같은 주제 문제 - [A 32-year-old pregnant woman at 28 weeks gestation presents to the prenatal clinic with co…](https://mymerci.kr/pages/nclex_q.php?qn_id=542840) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._