# A pregnant client at 32 weeks gestation is diagnosed with hepatitis B. Which assessment finding would be most concerning to the nurse? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542888 > language: ko > subject: Maternal Newborn Health ## 문제 A pregnant client at 32 weeks gestation is diagnosed with hepatitis B. Which assessment finding would be most concerning to the nurse? ## 보기 1. Mild fatigue and decreased appetite with slight weight loss 2. Clay-colored stools and dark urine with mild jaundice 3. Elevated liver enzymes (ALT and AST) with mild pruritus 4. Severe right upper quadrant pain with nausea and vomiting **✔ 정답** **정답: 4** ## 해설 Severe right upper quadrant pain with nausea and vomiting indicates potential fulminant hepatitis or acute liver failure, a life-threatening emergency requiring immediate intervention. Other options are common hepatitis B symptoms but less urgent. ## 심화 해설 Clinical Context & Core Concern This question presents a pregnant client at 32 weeks gestation with a known diagnosis of hepatitis B. The nurse must identify the most concerning assessment finding. While hepatitis B itself causes hepatic inflammation, the priority is recognizing signs that her chronic condition is acutely worsening into a life-threatening state, such as fulminant liver failure. The correct answer is the option indicating severe right upper quadrant pain with nausea and vomiting. Pathophysiology & Clinical Reasoning To understand why option 4 is the priority, we must differentiate between the expected manifestations of acute or chronic hepatitis and the ominous signs of acute decompensation. Options 1, 2, and 3 describe findings commonly associated with hepatocellular injury and cholestasis. Mild fatigue, anorexia, jaundice, dark urine, clay-colored stools, elevated liver enzymes (ALT, AST), and pruritus are all classic symptoms resulting from the liver's impaired ability to process bilirubin and metabolic wastes. These are concerning and require monitoring, but they represent the typical disease trajectory [3]. Option 4, however, points toward a rapid and severe escalation. The development of severe right upper quadrant (RUQ) pain accompanied by nausea and vomiting is highly suggestive of acute hepatic capsular distension and intense parenchymal inflammation. This clinical picture can be a prodrome to fulminant hepatic failure, a rare but catastrophic complication where massive hepatocellular necrosis occurs over days. In the context of a pregnant patient, the differential must also include acute fatty liver of pregnancy and severe drug-induced liver injury, which can mimic this presentation [3]. The urgency lies in the fact that this symptom cluster may herald rapid progression to coagulopathy, encephalopathy, and multi-organ failure, demanding immediate, intensive intervention [1, 4]. Critical Nursing Judgment & NCLEX Priority The NCLEX-RN exam consistently tests the nurse's ability to prioritize based on acuity and the risk for rapid deterioration. Using the nursing process, the nurse must analyze which cue represents a change from a chronic, stable condition to an acute, unstable one. While laboratory values (option 3) and cholestatic symptoms (option 2) provide important data, the patient's subjective report of severe pain and unrelenting nausea is a critical clinical cue. Pain of this nature signals active, ongoing tissue damage and capsular stretching, which can precede a systemic inflammatory response and hemodynamic instability. The nurse must recognize this as the highest priority finding, warranting an immediate comprehensive assessment and urgent provider notification to rule out fulminant liver failure or other emergent hepatic pathology [1, 4]. References (research sources) - [3]Liver function disorders in pregnancy: physiology or pathology?Research articleSielwanowska-Lasek W, Mądro A. (2026) · DOI: 10.5114/pg.2026.160319 ## 임상 시나리오 Clinical Practice Guide: Acute Deterioration in Hepatitis B During Pregnancy Key Assessment Findings - **Most Concerning:** Severe right upper quadrant pain, nausea, vomiting, and signs of encephalopathy (confusion, asterixis) suggest fulminant hepatic failure. - **Expected Symptoms:** Mild fatigue, anorexia, jaundice, dark urine, clay-colored stools, and pruritus are typical of hepatitis-related cholestasis and do not alone indicate imminent decompensation. - **Laboratory Trends:** Rapidly rising bilirubin, prolonged PT/INR, and decreasing ALT/AST (enzyme exhaustion) are more ominous than elevated transaminases alone. Immediate Nursing Actions - Place the client on continuous cardiac and oxygen saturation monitoring. - Assess level of consciousness hourly using a standardized tool (e.g., Glasgow Coma Scale). - Notify the provider immediately and prepare for urgent transfer to a higher level of care (ICU). - Anticipate orders for coagulation studies, serum ammonia, and imaging (ultrasound with Doppler). - Ensure IV access with two large-bore catheters and initiate fluid resuscitation as prescribed. - Prepare for possible emergent delivery if maternal status deteriorates, coordinating with obstetrics and neonatology. Perinatal Considerations - Fulminant liver failure carries high maternal and fetal mortality; fetal monitoring should be continuous. - Administer hepatitis B immune globulin (HBIG) and the first dose of hepatitis B vaccine to the newborn within 12 hours of delivery, regardless of maternal decompensation. - Document all medications carefully, avoiding hepatotoxic agents (e.g., acetaminophen, certain anticonvulsants). ## 핵심 개념 - **Fulminant Liver Failure** — Rapid, severe deterioration of liver function in a patient without pre-existing liver disease, often presenting with encephalopathy and coagulopathy. - **Hepatic Capsular Distension** — Stretching of the liver capsule (Glisson's capsule) due to rapid parenchymal swelling or inflammation, causing severe right upper quadrant pain. - **Cholestasis** — Reduction or stoppage of bile flow, leading to jaundice, dark urine, clay-colored stools, and pruritus from retained bile salts. ## 같은 주제 문제 - [A pregnant client at 32 weeks gestation is diagnosed with hepatitis B. 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