# A pregnant client at 28 weeks gestation is diagnosed with pulmonary tuberculosis. Which assessment finding would be most concerning to the nurse? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542961 > language: ko > subject: Adult Health ## 문제 A pregnant client at 28 weeks gestation is diagnosed with pulmonary tuberculosis. Which assessment finding would be most concerning to the nurse? ## 보기 1. Mild ankle edema that resolves with leg elevation 2. Decreased fetal movement for a two-hour period 3. Weight gain of two pounds over one week 4. Hemoptysis with increased respiratory distress **✔ 정답** **정답: 4** ## 해설 Hemoptysis with increased respiratory distress indicates active disease progression and respiratory compromise, posing immediate risks to maternal and fetal oxygenation. Other findings (ankle edema, decreased fetal movement, weight gain) are less urgent in this context. ## 심화 해설 Understanding the Clinical Priority When caring for a pregnant client at 28 weeks gestation with active pulmonary tuberculosis, the nurse must prioritize assessment findings that indicate a life-threatening complication or a direct threat to maternal-fetal well-being. The physiological and immunological changes of pregnancy, as noted in the provided review, can obscure classic TB symptoms, making vigilant assessment for signs of clinical deterioration essential. The most concerning finding is the one that signals a breach in maternal respiratory function or an acute compromise in fetal status. Analysis of the Options - Option 1: Mild ankle edema that resolves with leg elevation. This is a common and typically benign finding in the third trimester due to pressure from the gravid uterus on the vena cava, leading to dependent edema. While it requires monitoring, it does not represent an immediate threat in the context of active TB. - Option 2: Decreased fetal movement for a two-hour period. While a change in fetal movement warrants further investigation with a non-stress test or biophysical profile, a single two-hour period of decreased movement can sometimes be related to fetal sleep cycles. It is concerning but does not carry the same immediate, life-threatening implication as active hemorrhage and airway compromise. - Option 3: Weight gain of two pounds over one week. A weight gain of 2 lbs in one week is slightly above the expected 1 lb per week in the third trimester. This could indicate fluid retention and requires monitoring for preeclampsia, but it is not the most acute, critical finding in this scenario. - Option 4: Hemoptysis with increased respiratory distress. This is the most critical finding. Hemoptysis (coughing up blood) indicates erosion of a blood vessel in the lung parenchyma, a severe complication of cavitary pulmonary TB. Combined with increased respiratory distress, it signals a rapid decline in gas exchange and potential for massive hemorrhage and airway obstruction. This represents a medical emergency requiring immediate intervention to protect the airway and stabilize both the mother and fetus. Pathophysiology and Clinical Reasoning The diagnosis of tuberculosis in pregnancy presents a major clinical challenge because the disease can contribute to adverse maternal outcomes [1]. The finding of hemoptysis with escalating respiratory distress directly reflects the underlying pathophysiology of a reactivated or progressive tubercular cavity eroding into the bronchial circulation. This leads to an immediate threat to maternal oxygenation. Maternal hypoxemia from any cause, including acute pulmonary hemorrhage, rapidly translates to fetal hypoxemia, as fetal oxygen delivery is entirely dependent on maternal arterial oxygen content and uteroplacental perfusion. While all options require nursing action, the principle of airway, breathing, and circulation (ABCs) dictates that a hemorrhagic respiratory complication takes absolute priority over dependent edema, a potential fetal sleep cycle, or a pattern of excessive weight gain. References (research sources) - [1]Tuberculosis in Pregnancy: An Updated Narrative Review.Research articleLongo C, Pontes KFM, Faíco MMM, Melo MM, Callado GY, Barbosa CB, Araujo Júnior E, Braga A. (2026) · DOI: 10.3390/diagnostics16111576 ## 임상 시나리오 Clinical Guide: Managing Active Pulmonary TB with Hemoptysis at 28 Weeks Gestation **Scenario:** A pregnant client at 28 weeks gestation with diagnosed pulmonary tuberculosis presents with hemoptysis and increased respiratory distress. This is a **maternal-fetal emergency** requiring immediate, coordinated intervention to prevent respiratory failure and fetal hypoxia. Immediate Nursing Actions - **Activate Emergency Response:** Call for the rapid response team and notify the obstetric and medical providers simultaneously. - **Airway and Breathing Assessment:** Place the client in a semi-Fowler’s or left lateral position to optimize ventilation and uterine perfusion. Administer supplemental oxygen to maintain maternal SpO2 above 95%. - **Hemorrhage Control:** Estimate the amount of blood loss. Keep the client NPO in case emergency bronchoscopy or surgical intervention is needed. Have suction equipment ready to prevent aspiration. - **Fetal Surveillance:** Initiate continuous electronic fetal monitoring to assess for signs of fetal distress (late decelerations, minimal variability, bradycardia) secondary to maternal hypoxia. Key Pathophysiology Hemoptysis in active TB results from erosion of a bronchial artery or cavitary lesion rupture. In pregnancy, increased vascularity and the physiological elevation of the diaphragm can worsen respiratory compromise. Maternal hypoxemia rapidly leads to fetal hypoxemia, making airway protection the absolute priority. Infection Control Precautions Maintain strict airborne precautions. Place a surgical mask on the client if transport is necessary. All staff must wear fitted N95 respirators. The client should remain in a negative-pressure isolation room. Pharmacological Considerations Standard first-line TB therapy (isoniazid, rifampin, ethambutol) is generally safe in pregnancy and should not be interrupted. Avoid streptomycin due to fetal ototoxicity. Pyridoxine supplementation is essential to prevent neuropathy. Prepare for possible administration of tranexamic acid or interventional radiology consultation if bleeding persists. Differential Assessment of Other Findings - **Mild ankle edema:** Reassure the client that this is expected in the third trimester but document and monitor for asymmetry or pitting that could suggest preeclampsia. - **Decreased fetal movement:** If reported without hemoptysis, perform a non-stress test. However, in the context of acute maternal distress, it is a secondary sign of fetal compromise. - **Weight gain:** A 2-lb weekly gain warrants dietary counseling but is not an acute priority during a hemorrhagic event. ## 핵심 개념 - **Hemoptysis** — Expectoration of blood from the respiratory tract, indicating possible cavitary lesions, bronchial erosion, or active pulmonary hemorrhage. - **Pulmonary Tuberculosis in Pregnancy** — Active TB infection of the lungs during gestation; physiological changes can mask symptoms, requiring high vigilance for respiratory deterioration. - **Maternal-Fetal Prioritization** — A triage principle where the nurse first addresses conditions threatening maternal airway, breathing, or circulation, as maternal stability directly impacts fetal well-being. - **Dependent Edema** — Swelling in the lower extremities caused by gravity and pressure from the gravid uterus on the vena cava, common and often benign in late pregnancy. - **Third Trimester Weight Gain** — Expected pattern of approximately 1 lb per week; slight deviations require dietary review but are not immediate emergencies. ## 같은 주제 문제 - [A 45-year-old patient with suspected pulmonary tuberculosis presents to the emergency depa…](https://mymerci.kr/pages/nclex_q.php?qn_id=541353) - [A nurse is assessing a 38-year-old patient who has been receiving treatment for pulmonary …](https://mymerci.kr/pages/nclex_q.php?qn_id=541354) - [A 65-year-old retired teacher presents to the emergency department with a 3-week history o…](https://mymerci.kr/pages/nclex_q.php?qn_id=541355) - [A 45-year-old patient with suspected pulmonary tuberculosis presents to the emergency depa…](https://mymerci.kr/pages/nclex_q.php?qn_id=541356) - [A nurse is caring for a patient with active pulmonary tuberculosis who has been on anti-tu…](https://mymerci.kr/pages/nclex_q.php?qn_id=541357) - [A nurse is assessing a patient with active pulmonary tuberculosis who has been on anti-tub…](https://mymerci.kr/pages/nclex_q.php?qn_id=541358) - [A nurse is caring for a patient with community-acquired pneumonia who has been on antibiot…](https://mymerci.kr/pages/nclex_q.php?qn_id=541359) - [A nurse is caring for a patient with active pulmonary tuberculosis who has been receiving …](https://mymerci.kr/pages/nclex_q.php?qn_id=541360) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._