# 階段 1 — 辨識線索。請點擊需要立即提升母胎照護層級的四個發現之「目前資料」欄位。 > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568576&lang=zh-tw > language: zh-TW > subject: Reduction of Risk Potential > category: ROR ## 題目 階段 1 — 辨識線索。請點擊需要立即提升母胎照護層級的四個發現之「目前資料」欄位。 | 發現 | 目前資料 | | --- | --- | | 血壓 | 172/114 及 170/112 mm Hg，間隔 15 分鐘 | | 神經學症狀 | 持續嚴重頭痛與視覺斑點 | | 疼痛與實驗室檢查結果 | 右上腹痛，血小板 88,000/mm3，AST 126 units/L | | 胎兒狀況 | 最小變異性合併反覆晚期減速 | | 四肢 | 雙側腳踝 1+ 水腫 | | 體溫 | 36.9 C | ## 解析 持續的嚴重血壓升高、腦部症狀、合併血小板減少與肝臟損傷的右上腹痛，以及伴隨最小變異性的反覆晚期減速，皆為緊急的嚴重特徵或胎兒窘迫發現。單純的輕度腳踝水腫不具特異性。 ## 深入解析 快速解答 請立即提升照護層級以處理持續的嚴重高血壓、神經學症狀、HELLP 模式發現，以及非令人安心的胎兒監視圖形。 為何此為正確答案 嚴重血壓升高會增加產婦中風風險；頭痛與視覺變化表示腦部受侵犯；右上腹痛、血小板偏低與肝酵素升高表示器官損傷；反覆晚期減速則暗示胎兒窘迫。 簡易類比或心智圖像 將此病歷視為兩個相互連動的警報面板：產婦面板顯示腦部、血壓與肝臟血小板的危險，而胎兒面板則顯示耐受性下降。任一面板皆可能需要緊急處置。 記憶訣竅 血壓、腦部、肝臟血小板、胎兒：四個警報。 NCLEX 決策規則 當懷孕期高血壓達到嚴重範圍，或伴隨神經學、器官損傷或胎兒窘迫線索時，請立即提升照護層級並同時評估母親與胎兒。 為何其他選項錯誤 輕度依賴性水腫常見且不具特異性，而正常的體溫並不會降低高血壓或胎兒緊急狀況的嚴重性。 References 1ACOG: Preeclampsia and High Blood Pressure During PregnancySevere features, maternal-fetal deterioration, hospitalization, and delivery planning 2ACOG Practice Bulletin 222: Gestational Hypertension and PreeclampsiaUrgent blood-pressure control, magnesium monitoring, and severe-feature management; reaffirmed 2026 ## 臨床情境 病情更新 產科檢傷 — 一位妊娠 34 週又 2 天的個案主訴嚴重頭痛、視覺變化與右上腹痛。 ## 相同主題題目 - [A 52-year-old patient is admitted with severe acute pancreatitis. Lipase is 1,800 U/L and …](https://mymerci.kr/pages/nclex_q.php?qn_id=372851&lang=zh-tw) - [A 68-year-old is admitted for acute uncomplicated diverticulitis with WBC 16,000/uL and pe…](https://mymerci.kr/pages/nclex_q.php?qn_id=372855&lang=zh-tw) - [A patient with end-stage renal disease is post-op day 1 from a left forearm arteriovenous …](https://mymerci.kr/pages/nclex_q.php?qn_id=373261&lang=zh-tw) - [A 72-year-old presents to the ED with sudden right-sided weakness and aphasia. Family stat…](https://mymerci.kr/pages/nclex_q.php?qn_id=373516&lang=zh-tw) - [A 65-year-old is post-op day 1 from a hip arthroplasty. Which nursing action best supports…](https://mymerci.kr/pages/nclex_q.php?qn_id=373882&lang=zh-tw) - [A nurse is implementing the CDC STEADI fall-prevention initiative for community-dwelling o…](https://mymerci.kr/pages/nclex_q.php?qn_id=374875&lang=zh-tw) - [A patient on day 7 of heparin therapy has a platelet count drop from 220,000 to 80,000 ove…](https://mymerci.kr/pages/nclex_q.php?qn_id=374929&lang=zh-tw) - [An 18-year-old with sickle cell disease arrives in vaso-occlusive crisis with severe back …](https://mymerci.kr/pages/nclex_q.php?qn_id=374972&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=568576&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=568576&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=568576&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=568576&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=568576&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_