# A nurse is assessing a 28-year-old primigravida 12 hours after vaginal delivery of a healthy 3,200g infant following a prolonged labor of 18 hours. Which assessment finding would be the priority concern requiring immediate intervention?

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> subject: Maternal Newborn Health

## 문제

A nurse is assessing a 28-year-old primigravida 12 hours after vaginal delivery of a healthy 3,200g infant following a prolonged labor of 18 hours. Which assessment finding would be the priority concern requiring immediate intervention?

A 28-year-old primigravida delivered a healthy 3,200g infant vaginally 12 hours ago after a prolonged labor of 18 hours. During the assessment, the nurse notes the client's vital signs and performs a comprehensive postpartum evaluation.

## 보기

1. Fundus located 2 cm above the umbilicus and slightly deviated to the right
2. Lochia rubra with small clots and saturating one pad every 2 hours
3. Episiotomy site with mild edema and intact sutures
4. Blood pressure 160/110 mmHg with headache and visual disturbances **✔ 정답**

**정답: 4**

## 해설

Blood pressure 160/110 mmHg with headache and visual disturbances indicates hypertensive crisis requiring immediate intervention for preeclampsia. Other findings are normal or less urgent postpartum assessments.

## 심화 해설

Clinical Context

This postpartum assessment scenario targets the early recognition of hypertensive disorders of pregnancy that can persist or newly manifest after delivery. A 28-year-old primigravida with a history of prolonged labor is now 12 hours postpartum. While routine involution and lochia assessments are essential, the nurse must prioritize findings that signal impending maternal morbidity, particularly those related to the cardiovascular and central nervous systems.

Why Option 4 Is the Priority

A blood pressure of 160/110 mmHg accompanied by headache and visual disturbances meets the diagnostic threshold for severe postpartum preeclampsia. The presence of neurologic symptoms indicates that cerebral autoregulation is failing, placing the patient at immediate risk for eclampsia, hemorrhagic stroke, or posterior reversible encephalopathy syndrome (PRES). The transition gap during the fourth trimester is a recognized period of vulnerability; traditional management strategies often fail to capture late-onset or persistent preeclampsia after discharge, making in-hospital recognition critical for timely intervention [3]. Immediate actions include seizure precautions, administration of magnesium sulfate, and urgent antihypertensive therapy to prevent progression to eclamptic seizure or intracranial catastrophe.

Analysis of Other Options

- Option 1: A fundus located 2 cm above the umbilicus and deviated to the right is a classic sign of a distended bladder impeding uterine involution. This is a common and expected finding at 12 hours postpartum that requires assisting the patient to void and reassessing. It does not represent an immediate threat to maternal life.

- Option 2: Lochia rubra saturating one pad every 2 hours falls within the expected range for this stage of recovery. Small clots are also normal as the placental site heals. This finding indicates a typical involution process and does not suggest postpartum hemorrhage.

- Option 3: Mild edema at an episiotomy site with intact sutures is an anticipated local tissue response to trauma and repair. While comfort measures and ongoing observation are needed, this finding does not signal a systemic emergency.

Pathophysiology and Clinical Reasoning

Preeclampsia is rooted in abnormal placentation and systemic endothelial dysfunction, which does not immediately resolve with delivery of the placenta. The exaggerated systemic inflammatory response and vasospasm can persist or even intensify postpartum. Women with a history of preeclampsia are at increased risk for postpartum mood and psychological disorders, underscoring the need for comprehensive surveillance that extends beyond physical parameters . In this scenario, the severe-range blood pressure with cerebral symptoms indicates that the endothelial injury is affecting the cerebral vasculature, demanding immediate pharmacologic intervention to prevent permanent neurological injury or death.

NCLEX-RN Testing Concept

This question tests the principle of prioritization using a maternal early warning framework. When multiple assessment findings are present, the nurse must identify the cue that signals an evolving systemic crisis with the highest potential for rapid deterioration. Severe hypertension with neurologic manifestations always takes precedence over expected postpartum changes or localized discomfort. The nurse must also recognize that conventional nursing care pathways may need augmentation with structured, evidence-based protocols to optimize recovery in this high-risk population .References (research sources)

- [3]Optimizing the Transition of Care for Postpartum Preeclampsia: A Scoping Review of Management Strategies and Missed Opportunities.Research articleChrestay NZ, Chrestay NO, Brotman M. (2026) · DOI: 10.7759/cureus.108253

## 임상 시나리오

Clinical Practice Guide: Postpartum Preeclampsia Recognition

**Scenario:** A 28-year-old primigravida, 12 hours post-vaginal delivery after an 18-hour prolonged labor, presents with BP 160/110 mmHg, severe headache, and visual disturbances.

Priority Nursing Actions

- **Ensure Immediate Safety:** Initiate seizure precautions (padded side rails, suction and oxygen at bedside, call light within reach). Maintain a quiet, dimly lit environment to minimize CNS stimulation.

- **Notify Provider:** Urgently report findings and anticipate orders for IV magnesium sulfate (loading dose 4-6g over 15-20 minutes, then maintenance 1-2g/hour) and an IV antihypertensive (e.g., labetalol 20mg IV push, hydralazine 5-10mg IV push).

- **Continuous Monitoring:** Assess vital signs every 15 minutes until stable. Monitor deep tendon reflexes (DTRs) hourly and respiratory rate hourly for magnesium toxicity (absent DTRs, RR < 12/min, decreased urine output).

- **Fetal/Neonatal Context:** While the infant is delivered, maternal stabilization is the priority to prevent eclampsia, hemorrhagic stroke, or PRES.

Key Assessment Pitfalls

- **Do not dismiss hypertension as anxiety or pain:** A BP ≥ 160/110 mmHg with neurological symptoms is a hypertensive emergency, not a benign variant.

- **Differentiate from normal postpartum changes:** A displaced fundus (full bladder) or moderate lochia rubra are common and managed conservatively; they do not take priority over severe preeclampsia.

- **Recognize the "fourth trimester" vulnerability:** Preeclampsia can occur for the first time up to 6 weeks postpartum. All postpartum discharge education must include warning signs: severe headache, vision changes, epigastric pain, and shortness of breath.

Evidence-Based Management

Magnesium sulfate remains the gold standard for seizure prophylaxis in severe preeclampsia/eclampsia. Antihypertensive therapy should target a BP of ≤ 150/100 mmHg to prevent maternal cerebrovascular events while maintaining uteroplacental perfusion (though the placenta is now delivered, the principles of gradual reduction apply).

## 핵심 개념

- **Postpartum Preeclampsia** — New-onset hypertension with proteinuria or end-organ dysfunction occurring after delivery, typically within 48 hours but can present up to 6 weeks postpartum.
- **Eclampsia** — The onset of generalized tonic-clonic seizures in a patient with preeclampsia, representing a life-threatening progression of the disease.
- **Cerebral Autoregulation** — The brain's ability to maintain constant blood flow despite changes in systemic blood pressure; failure in severe hypertension leads to hyperperfusion and edema.
- **Lochia Rubra** — The first stage of postpartum uterine discharge, consisting mainly of blood, lasting for the first 3-4 days after delivery.
- **Fundal Assessment** — Palpation of the uterine fundus to evaluate involution; a boggy or displaced fundus often indicates a distended bladder.

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