# Situation: The nurse at a lying-in clinic holds a mothers' class for women between 28 and 36 weeks' gestation whose pregnancies have been uncomplicated. Before the class, the nurse checks four women's blood pressure and asks what they have noticed: 30 weeks: dizzy when lying on her back, relieved by turning to her side; blood pressure 104/64 mmHg 32 weeks: ankles swell by evening and are normal by morning; blood pressure 138/88 mmHg, similar to her readings since early pregnancy 34 weeks: face and fingers have become puffy over the past 2 days; blood pressure 128/80 mmHg 35 weeks: short of breath climbing stairs, comfortable at rest; blood pressure 118/76 mmHg Which woman should the nurse send for evaluation the same day?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629470  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse at a lying-in clinic holds a mothers' class for women between 28 and 36 weeks' gestation whose pregnancies have been uncomplicated.

Before the class, the nurse checks four women's blood pressure and asks what they have noticed:
30 weeks: dizzy when lying on her back, relieved by turning to her side; blood pressure 104/64 mmHg
32 weeks: ankles swell by evening and are normal by morning; blood pressure 138/88 mmHg, similar to her readings since early pregnancy
34 weeks: face and fingers have become puffy over the past 2 days; blood pressure 128/80 mmHg
35 weeks: short of breath climbing stairs, comfortable at rest; blood pressure 118/76 mmHg
Which woman should the nurse send for evaluation the same day?

## 보기

1. The woman at 30 weeks
2. The woman at 32 weeks
3. The woman at 34 weeks **✔ 정답**
4. The woman at 35 weeks

**정답: 3**

## 해설

New swelling of the face and hands is a danger sign that may signal preeclampsia and needs same-day evaluation even when one blood pressure reading is normal. A reading of 138/88 mmHg is below the 140/90 mmHg threshold, and dependent ankle edema that resolves overnight is a common discomfort. Dizziness relieved by turning to the side is supine hypotension, and mild breathlessness on exertion is expected in late pregnancy.

## 심화 해설

The woman who needs same-day evaluation
Among the four women, only the one at 34 weeks has a danger sign: new puffiness of the face and fingers that has developed over the past 2 days. Swelling of the face and hands, as opposed to dependent swelling of the ankles, can be an early sign of preeclampsia. Her blood pressure today is 128/80 mmHg, which is normal, but a single normal reading does not rule out the condition. New swelling of the face and hands in late pregnancy is a danger sign that needs same-day evaluation, even with a normal blood pressure reading.

Why a normal reading does not reassure
Preeclampsia can evolve quickly, and blood pressure varies from reading to reading. Generalized edema reflects fluid shifting out of the blood vessels because of endothelial damage, which is part of the disease process. Same-day evaluation lets the provider repeat blood pressure measurements, test the urine for protein, review symptoms such as headache, visual changes, and epigastric pain, and assess the fetus. Sending her home with advice alone could delay the diagnosis of a condition that can progress to eclampsia.

Interpreting the other three women

| Week | Finding | Interpretation |
| --- | --- | --- |
| 30 weeks | Dizziness lying on her back, relieved by turning to her side; BP 104/64 mmHg | Supine hypotensive syndrome; teach her to avoid lying flat |
| 32 weeks | Ankle swelling by evening, gone by morning; BP 138/88 mmHg, similar since early pregnancy | Below the 140/90 mmHg threshold; dependent edema is a common discomfort |
| 34 weeks | New puffy face and fingers for 2 days; BP 128/80 mmHg | Danger sign; same-day evaluation |
| 35 weeks | Short of breath on stairs, comfortable at rest; BP 118/76 mmHg | Expected as the enlarging uterus raises the diaphragm |

The distractor that looks most worrying
Watch out! The woman at 32 weeks has the highest blood pressure of the four, and many test-takers choose her. Her reading of 138/88 mmHg is still below the 140/90 mmHg threshold for hypertension in pregnancy, and it has been similar since early pregnancy, so it is not a new rise. Her ankle swelling is dependent edema that resolves overnight, which is a normal discomfort of late pregnancy. She still needs routine follow-up and teaching on danger signs, but not same-day referral.

Exam takeaway
Distinguish dependent ankle edema, which is common, from new edema of the face and hands, which is a danger sign. Key point! When choosing whom to refer, look for a new change that matches a known danger sign rather than simply the highest number. Mothers' classes are a good opportunity to teach every pregnant woman the danger signs that should bring her back to the facility the same day, including swelling of the face and hands, severe headache, blurred vision, and vaginal bleeding.

## 임상 시나리오

Prenatal Danger Sign TriageFour women between 30 and 35 weeks
New swelling of the face and fingers is a danger sign that may signal preeclampsia and needs same-day evaluation, even with a normal blood pressure.

A reading below 140/90 mmHg that has been stable since early pregnancy, with ankle swelling that clears overnight, is a common discomfort.

Dizziness relieved by turning to the side is supine hypotension; mild breathlessness on exertion is expected late in pregnancy.

CautionDo not rely on a single normal blood pressure reading to dismiss new facial or hand edema.

## 핵심 개념

- **Preeclampsia** — A pregnancy disorder after 20 weeks with new hypertension and signs of organ involvement such as proteinuria.
- **Dependent edema** — Swelling of the lower legs and ankles that worsens with standing and improves with rest or overnight.
- **Supine hypotensive syndrome** — Low blood pressure and dizziness when lying on the back because the uterus compresses the inferior vena cava.
- **Danger signs of pregnancy** — Warning symptoms such as facial edema, severe headache, blurred vision, or bleeding that need prompt evaluation.

## 같은 주제 문제

- [Situation: A 26-year-old woman comes to the Rural Health Unit (RHU) for her first prenatal…](https://mymerci.kr/pages/nclex_q.php?qn_id=629366)
- [Situation: A 26-year-old woman comes to the Rural Health Unit (RHU) for her first prenatal…](https://mymerci.kr/pages/nclex_q.php?qn_id=629367)
- [Situation: A 26-year-old woman comes to the Rural Health Unit (RHU) for her first prenatal…](https://mymerci.kr/pages/nclex_q.php?qn_id=629368)
- [Situation: A 26-year-old woman comes to the Rural Health Unit (RHU) for her first prenatal…](https://mymerci.kr/pages/nclex_q.php?qn_id=629369)
- [Situation: A 30-year-old primigravida at 30 weeks' gestation attends a prenatal check-up a…](https://mymerci.kr/pages/nclex_q.php?qn_id=629370)
- [Situation: A 30-year-old primigravida at 30 weeks' gestation attends a prenatal check-up a…](https://mymerci.kr/pages/nclex_q.php?qn_id=629371)
- [Situation: A 30-year-old primigravida at 30 weeks' gestation attends a prenatal check-up a…](https://mymerci.kr/pages/nclex_q.php?qn_id=629372)
- [Situation: A 30-year-old primigravida at 30 weeks' gestation attends a prenatal check-up a…](https://mymerci.kr/pages/nclex_q.php?qn_id=629373)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._