# A nurse is assessing a pregnant client at 32 weeks gestation with a pre-pregnancy BMI of 28 kg/m². 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=542967 > language: ko > subject: Maternal Newborn Health ## 문제 A nurse is assessing a pregnant client at 32 weeks gestation with a pre-pregnancy BMI of 28 kg/m². Which assessment finding would be most concerning and require immediate intervention? ## 보기 1. Blood pressure reading of 128/82 mmHg 2. Proteinuria 2+ on dipstick with facial edema **✔ 정답** 3. Fasting blood glucose level of 105 mg/dL 4. Weight gain of 12 pounds since conception **정답: 2** ## 해설 Proteinuria 2+ with facial edema suggests preeclampsia, a serious complication requiring immediate intervention in obese pregnant women. Other findings are less urgent or within normal limits. ## 심화 해설 Clinical Reasoning and Priority Setting This clinical scenario presents a pregnant client at 32 weeks gestation with a pre-pregnancy BMI of 28 kg/m², placing her in an overweight category and at increased risk for hypertensive disorders of pregnancy. The task is to identify the most concerning finding that requires immediate intervention, which necessitates differentiating between expected physiological changes, common pregnancy complications, and a potential obstetric emergency. Analysis of Assessment Findings The correct answer is the combination of proteinuria 2+ on dipstick with facial edema. This presentation is highly suggestive of preeclampsia, a multisystem progressive disorder characterized by new-onset hypertension and proteinuria, or hypertension with end-organ damage, after 20 weeks of gestation. The presence of facial edema, while not diagnostic on its own, becomes a significant red flag when coupled with significant proteinuria, as it indicates a shift from a benign condition to one with potential for rapid deterioration. Preeclampsia involves systemic endothelial dysfunction, which is the underlying mechanism linking these findings. The meta-analysis on maternal depressive symptoms and preeclampsia risk underscores the importance of recognizing preeclampsia as a complex condition with various risk factors, but the immediate clinical priority is the recognition of its overt signs. The study on smartphone-based blood pressure monitoring reinforces that the combination of blood pressure measurement and urine protein assessment remains the cornerstone of screening and diagnosis, highlighting that the presence of proteinuria is a key indicator of disease severity beyond hypertension alone. The other options, while requiring attention, do not represent the same level of immediate threat: - A blood pressure of 128/82 mmHg is mildly elevated but does not meet the threshold for a hypertensive emergency or even the diagnostic criterion for preeclampsia (systolic ≥140 mmHg or diastolic ≥90 mmHg on two occasions). It requires close monitoring but not immediate, emergent intervention in isolation. - A fasting blood glucose of 105 mg/dL is elevated and indicative of gestational diabetes mellitus (GDM). The meta-analysis on the triglyceride-glucose index highlights how early-pregnancy insulin resistance is a predictor for GDM and adverse outcomes. While GDM requires prompt management to prevent fetal macrosomia and neonatal hypoglycemia, it does not pose the same acute, immediate risk of maternal seizure, stroke, or placental abruption as evolving preeclampsia. - A total weight gain of 12 pounds at 32 weeks is within the recommended range for an overweight woman (recommended total gain of 15-25 pounds), making this an expected finding rather than a concerning one. Pathophysiological Rationale and Clinical Implications The core pathophysiological concern is the progression of preeclampsia. The finding of proteinuria 2+ indicates significant glomerular capillary endotheliosis, a hallmark renal lesion of preeclampsia where the glomeruli become swollen and leak protein. This is a direct manifestation of the systemic endothelial dysfunction that characterizes the disease. The concurrent facial edema further supports a systemic process of capillary leak and fluid shift into the interstitial space. This combination signals that the disease has progressed beyond a purely hypertensive state to one with significant end-organ involvement, increasing the imminent risk for severe complications such as eclampsia (seizures), HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), renal failure, and abruptio placentae. The case report on rectus sheath hematoma illustrates a rare but catastrophic consequence of the endothelial dysfunction and vascular fragility inherent in severe preeclampsia, where even minor vessel injury can lead to concealed, life-threatening hemorrhage. This underscores why the recognition of preeclampsia with end-organ signs is a critical safety priority. Immediate interventions would include confirming the blood pressure, assessing deep tendon reflexes and clonus, evaluating for other signs of severe disease (epigastric pain, visual disturbances, headache), and notifying the provider for urgent admission, magnesium sulfate administration for seizure prophylaxis, and possibly expedited delivery planning. ## 임상 시나리오 Preeclampsia: Immediate Nursing Assessment & Intervention When a pregnant client presents with new-onset proteinuria and facial edema, a diagnosis of preeclampsia must be presumed until proven otherwise. This condition is a leading cause of maternal and fetal morbidity and mortality, requiring rapid, systematic intervention. 1. Priority Assessment & Triage - **Confirm Vital Signs:** Immediately recheck blood pressure using correct cuff size and technique. A reading of 140/90 mmHg or higher on two occasions at least 4 hours apart confirms hypertension. Severe features include BP 160/110 mmHg or higher. - **Assess for Severe Features:** Evaluate for signs of end-organ damage: severe headache unrelieved by acetaminophen, visual disturbances (blurred vision, scotomata), right upper quadrant or epigastric pain, nausea/vomiting, and oliguria. - **Perform Deep Tendon Reflexes (DTRs) and Clonus Check:** Hyperreflexia and clonus indicate central nervous system irritability and risk for eclampsia (seizures). - **Auscultate Lung Sounds:** Assess for crackles, which may indicate pulmonary edema, a severe complication. 2. Immediate Diagnostic Workup - **Confirm Proteinuria:** Send a clean-catch urine specimen for protein-to-creatinine ratio or a 24-hour urine collection. A value of 300 mg or more in 24 hours is diagnostic. - **Laboratory Studies (STAT):** Order a complete blood count (CBC) to assess for thrombocytopenia (platelets < 100,000/microliter), liver enzymes (AST, ALT) to detect liver involvement, and serum creatinine for renal function. - **Fetal Assessment:** Initiate continuous electronic fetal monitoring to evaluate for signs of fetal distress. Perform a biophysical profile or non-stress test as ordered. 3. Nursing Interventions & Seizure Precautions - **Institute Seizure Precautions:** Pad side rails, keep bed in lowest position, ensure suction equipment and oxygen are at the bedside, and maintain a quiet, dimly lit environment to reduce CNS stimulation. - **Administer Magnesium Sulfate:** Prepare for intravenous magnesium sulfate administration for seizure prophylaxis if severe features are present. Monitor for magnesium toxicity: loss of DTRs, respiratory depression ( ## 핵심 개념 - **Preeclampsia** — A multisystem progressive disorder of pregnancy characterized by new-onset hypertension and proteinuria, or hypertension with end-organ damage, occurring after 20 weeks of gestation. - **Proteinuria** — The presence of excess protein in the urine, a key diagnostic criterion for preeclampsia, often measured by dipstick (e.g., 2+ or greater). - **Gestational Hypertension** — New-onset hypertension (systolic BP 140 mmHg or higher or diastolic BP 90 mmHg or higher) after 20 weeks of pregnancy without proteinuria. - **Gestational Diabetes Mellitus (GDM)** — Carbohydrate intolerance with onset or first recognition during pregnancy, often screened for with fasting glucose or glucose tolerance tests. ## 같은 주제 문제 - [A nurse is assessing a pregnant client at 28 weeks gestation with a pre-pregnancy BMI of 3…](https://mymerci.kr/pages/nclex_q.php?qn_id=542968) - [A nurse is assessing a pregnant client at 36 weeks gestation with a pre-pregnancy BMI of 3…](https://mymerci.kr/pages/nclex_q.php?qn_id=542969) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._