# A 28-year-old pregnant woman at 32 weeks gestation presents to the labor and delivery unit with complaints of severe headache, blurred vision, and epigastric pain. Her blood pressure is 160/110 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=542971 > language: ko > subject: Maternal Newborn Health ## 문제 A 28-year-old pregnant woman at 32 weeks gestation presents to the labor and delivery unit with complaints of severe headache, blurred vision, and epigastric pain. Her blood pressure is 160/110 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. Blood pressure of 160/110 mmHg on repeated measurements 3. 3+ proteinuria on dipstick urinalysis 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 administration. Other findings (hypertension, proteinuria, edema) are typical of severe preeclampsia but less urgent. ## 심화 해설 Clinical Reasoning & Priority Setting The assessment finding that is most concerning and requires immediate intervention is hyperreflexia with sustained clonus. This finding is a hallmark of severe central nervous system (CNS) irritability, which signals a rapid progression from severe preeclampsia to eclampsia, a life-threatening obstetric emergency characterized by generalized tonic-clonic seizures . The pathophysiology underlying this progression involves disrupted cerebral autoregulation. In severe preeclampsia, systemic vasospasm and endothelial dysfunction lead to increased cerebral perfusion pressure. When the mean arterial pressure exceeds the brain's ability to constrict vessels, forced vasodilation and hyperperfusion occur, resulting in cerebral edema. This neuronal irritability manifests clinically as hyperreflexia and, in its most extreme form, sustained ankle clonus, indicating that the seizure threshold is critically low . While a blood pressure of 160/110 mmHg (Option 2) defines the severe range and requires antihypertensive therapy, the presence of clonus signifies impending eclampsia and demands emergent seizure prophylaxis, typically with intravenous magnesium sulfate, taking priority over blood pressure control alone . Similarly, 3+ proteinuria (Option 3) confirms the diagnosis of preeclampsia but does not, by itself, dictate the immediate risk of an eclamptic seizure. Ankle edema with a weight gain of 2 pounds in one week (Option 1) is a common finding related to generalized vasospasm and capillary leak, but it is not a direct indicator of imminent neurological deterioration. Therefore, the nurse must recognize that CNS signs take precedence in the clinical staging of severe preeclampsia, as the prevention of maternal seizures is the critical safety goal . ## 임상 시나리오 Clinical Management of Severe Preeclampsia with CNS Irritability The presence of hyperreflexia with sustained clonus in a patient with severe preeclampsia constitutes an obstetric emergency signaling impending eclampsia. Immediate intervention focuses on maternal seizure prophylaxis and stabilization. Priority Interventions - **Seizure Prophylaxis:** Administer intravenous magnesium sulfate per institutional protocol (typically a loading dose of 4-6 g over 15-20 minutes, followed by a maintenance infusion of 1-2 g/hour). Monitor for signs of magnesium toxicity (loss of deep tendon reflexes, respiratory depression, decreased urine output). - **Seizure Precautions:** Implement safety measures including padded side rails, a functioning suction setup, and oxygen available at the bedside. Maintain a quiet, dimly lit environment to minimize CNS stimulation. - **Blood Pressure Control:** Administer antihypertensive agents (e.g., IV labetalol or hydralazine) to maintain blood pressure below 160/105-110 mmHg, reducing the risk of maternal stroke while avoiding precipitous drops that could compromise uteroplacental perfusion. - **Maternal-Fetal Monitoring:** Initiate continuous electronic fetal monitoring and assess maternal vital signs, deep tendon reflexes, and level of consciousness every 15 minutes until stabilized. Pathophysiology Rationale Disrupted cerebral autoregulation from systemic vasospasm leads to cerebral hyperperfusion and edema. This neuronal irritability clinically manifests as hyperreflexia and clonus, indicating a critically low seizure threshold that magnesium sulfate effectively raises through calcium channel blockade and NMDA receptor antagonism. Definitive Treatment Delivery is the only definitive cure for preeclampsia/eclampsia. Once the patient is stabilized and seizure prophylaxis is established, preparations for delivery should be initiated, with the timing and mode dependent on maternal-fetal status and gestational age. ## 핵심 개념 - **Sustained Clonus** — A series of involuntary, rhythmic muscle contractions indicating severe central nervous system hyperexcitability and a critically low seizure threshold. - **Eclampsia** — The onset of generalized tonic-clonic seizures in a woman with preeclampsia, representing a life-threatening obstetric emergency. - **Cerebral Autoregulation** — The brain's intrinsic ability to maintain constant blood flow despite changes in perfusion pressure; disrupted in severe preeclampsia, leading to hyperperfusion and edema. - **Magnesium Sulfate** — The first-line agent for seizure prophylaxis in severe preeclampsia and eclampsia, acting as a central nervous system depressant. - **Severe Preeclampsia** — A hypertensive disorder of pregnancy characterized by blood pressure of 160/110 mmHg or higher and proteinuria, often with signs of end-organ damage. ## 같은 주제 문제 - [A nurse is assessing a 28-year-old pregnant client at 32 weeks gestation who presents to t…](https://mymerci.kr/pages/nclex_q.php?qn_id=542970) - [A nurse is assessing a 25-year-old pregnant woman at 30 weeks gestation who presents to th…](https://mymerci.kr/pages/nclex_q.php?qn_id=542972) - [A pregnant client at 32 weeks gestation is admitted with severe preeclampsia. 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