Case Study — Maternal-Newborn
Preeclampsia NGN Case Study
A Next Gen NCLEX-style unfolding case. Read each step, commit to your own answer — out loud or on paper — and only then reveal ours. The six steps mirror the NCSBN Clinical Judgment Measurement Model exactly as the exam tests it.
15 min activity · Maternal-Newborn
Educational use only. This case is a learning exercise with simplified values, not a treatment protocol — real preeclampsia care follows provider orders, your facility’s OB protocols, and magnesium dosing per pharmacy and provider. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
The Scenario
1330, OB triage: Ms. Bauer, 28, G1P0 at 34 weeks, comes in because her headache “won’t go away no matter what I take” — two days now, with new “sparkles” in her vision this morning. Her prenatal course was unremarkable until her last visit, when her BP was “a little up.” She mentions her rings stopped fitting this week.
1340 Assessment
- BP 168/112, repeated 15 min later: 172/110 · HR 88 · RR 18 · SpO₂ 98%
- Headache 7/10, frontal, unrelieved by acetaminophen; photopsia (“sparkles”)
- New epigastric/RUQ discomfort “like heartburn that sits under my ribs”
- Face and hands visibly edematous; deep tendon reflexes 3+ with no clonus
- Urine dip: 3+ protein · Fetal heart rate 142 with moderate variability
Step 1 — Recognize Cues
Which findings are most relevant — and which matter most right now? List the cues you would flag before revealing.
▸Reveal answer
Severe-range cues: two BPs ≥160/110 taken 15+ minutes apart, persistent headache unrelieved by analgesia, visual disturbances, and epigastric/RUQ pain — each of these is a severe feature, and she has four. Hyperreflexia (3+) signals CNS irritability — the runway to eclampsia.
Supporting cues: 3+ proteinuria, rapid-onset face/hand edema (the “rings” detail), first pregnancy (a classic risk factor), and the prior “a little up” BP.
The trap: filing the RUQ pain under heartburn. In a hypertensive pregnant patient, epigastric/RUQ pain is a stretched liver capsule until proven otherwise — it is one of the most ominous symptoms in obstetrics.
Step 2 — Analyze Cues
What conditions could explain this picture? Labs return: platelets 92,000 · AST 118 · ALT 102 · creatinine 1.1 · hemoglobin stable, no hemolysis markers yet. Connect the cues before revealing.
▸Reveal answer
Preeclampsia with severe features (confirmed): new hypertension after 20 weeks + proteinuria + severe-range BPs + neurologic symptoms + RUQ pain. The labs add thrombocytopenia and transaminitis.
HELLP syndrome (developing concern): low platelets and elevated liver enzymes are two of the three letters — hemolysis labs (LDH, smear, bilirubin) will be followed closely. HELLP can deteriorate fast and sometimes presents with deceptively mild BP elevation.
Ruled less likely: chronic hypertension (her early pregnancy BPs were normal), migraine (doesn’t explain proteinuria, labs, or edema), gallbladder disease (possible RUQ mimic, but the full pattern points one way).
Step 3 — Prioritize Hypotheses
What are the two clocks running on this patient? Rank what must be prevented, in order.
▸Reveal answer
1. Eclamptic seizure — headache, visual changes, and hyperreflexia say the CNS is irritable now. Seizure prophylaxis is the most urgent intervention.
2. Stroke from severe hypertension — sustained BPs ≥160/110 demand antihypertensive treatment within a protocol-defined window (commonly within 30–60 minutes); intracranial hemorrhage is the leading cause of preeclampsia deaths.
3. Progression to HELLP/abruption and fetal compromise — the platelets and liver enzymes set the trajectory; continuous fetal monitoring watches the second patient. The definitive cure is delivery; at 34 weeks, that conversation starts now.
Step 4 — Generate Solutions
What should the next two hours include? Draft your plan — interventions, monitoring, and environment.
▸Reveal answer
Anticipated orders: magnesium sulfate (loading dose then continuous infusion) for seizure prophylaxis; an IV antihypertensive (labetalol or hydralazine) for the severe-range BPs; antenatal corticosteroids (betamethasone) for fetal lung maturity at 34 weeks; serial labs (platelets, liver enzymes, hemolysis markers); continuous fetal monitoring.
Nursing setup: seizure precautions (padded rails, suction and oxygen at bedside, airway nearby), a quiet, dim, low-stimulation room, strict I&O with an indwelling catheter (oliguria worsens magnesium risk), and calcium gluconate immediately available — the magnesium antidote lives where the magnesium runs.
The monitoring trio on magnesium: respiratory rate, deep tendon reflexes, and urine output, on a schedule — plus level checks per protocol.
Step 5 — Take Action
1715, on the magnesium infusion: your scheduled check finds RR 10, deep tendon reflexes absent, and urine output 22 mL over the last hour. She is drowsy but rousable. What do you do, in order?
▸Reveal answer
This is magnesium toxicity — act in sequence: stop the magnesium infusion first, support her airway and breathing (oxygen, stimulate, prepare bag-mask), call the provider, and give calcium gluconate IV per order/protocol. Absent reflexes are the early warning; respiratory depression at RR 10 is the urgent one; cardiac effects come last and worst.
Why it happened: magnesium is renally cleared — her falling urine output let the level climb. A stat magnesium level confirms; the oliguria itself also signals worsening disease.
Afterward: continuous monitoring, recheck reflexes and RR, reassess the fetal strip (magnesium also relaxes the baby — expect decreased variability), and document the event and notifications. Seizure prophylaxis will be re-weighed against toxicity risk by the team — likely at a reduced rate with tighter level checks.
Step 6 — Evaluate Outcomes
Day 2: after betamethasone is complete and her labs plateau, the team delivers by induction; a 5 lb 1 oz girl goes to the NICU for transitional support. Mom’s BP is 148/94 on oral medication, reflexes 2+, magnesium continued. The family asks, “It’s over now, right?” What’s the honest evaluation?
▸Reveal answer
Improving: delivery removes the cause; no seizure ever happened — the central goal of everything you did; BP responding to treatment; labs stabilizing.
Not over: eclampsia can occur postpartum — a meaningful share of seizures happen after delivery, which is why magnesium typically continues for 24 hours postpartum and why the same RR/reflex/urine monitoring continues with it.
Going home: teach the warning signs that demand a call (headache, visual changes, RUQ pain, decreased urination, swelling that worsens) for the postpartum weeks, arrange early BP follow-up, and name the long game: preeclampsia raises her lifetime cardiovascular risk and recurrence risk in future pregnancies — her primary care provider should know this chapter.
Debrief — The Pattern to Keep
- ✦Headache + visual changes + RUQ pain + BP ≥160/110 = severe features; hyperreflexia says the seizure is near.
- ✦Epigastric/RUQ pain in a hypertensive pregnant patient is liver capsule, not heartburn.
- ✦Magnesium monitoring trio: respiratory rate, reflexes, urine output — and calcium gluconate within reach.
- ✦Toxicity sequence: reflexes vanish first, breathing slows second — stop the mag, support airway, give calcium.
- ✦Delivery treats preeclampsia but doesn't end it: postpartum seizures happen — magnesium and monitoring continue ~24h.