ESTUDYR
NCLEX-RN Case Study: Preeclampsia/Eclampsia
Client Scenario
0800 Labor & Delivery Triage: A 32-year-old female at 36 weeks gestation presents with a
"splitting headache" that was not relieved by Acetaminophen. She reports seeing "bright
spots" in her vision and feeling nauseated. She notes her wedding ring no longer fits due to
finger swelling.
Physical Assessment:
Neurological: 3+ patellar reflexes (hyperreflexia); 2 beats of clonus noted in the
ankles.
Visual: Reports blurred vision and scotoma (blind spots).
Edema: 2+ pitting edema in the lower extremities and facial puffiness.
Vital Signs: BP 172/112, HR 88, RR 18, Temp 98.6°F. Fetal Heart Rate (FHR) is
145/min with moderate variability.
Item 1: Recognizing Cues (Visual/Reflexes)
Question: The nurse assesses the client's deep tendon reflexes (DTRs). Which diagram
correctly identifies the location for testing the patellar reflex and what a 4+ result would
indicate?
Correct Findings to Identify:
✅Hyperreflexia (3+ or 4+)
✅Positive Clonus (Rhythmic oscillations when the foot is dorsiflexed)
✅Severe Hypertension (SBP > 160 or DBP > 110)
✅Visual Disturbances (Scotoma)
Rationale: Hyperreflexia and clonus are signs of central nervous system (CNS) irritability. In
preeclampsia, high blood pressure leads to cerebral edema, which irritates the nerves and
puts the client at risk for a seizure (Eclampsia).
Item 2: Analyzing Cues (Labs)
NCLEX-RN Case Study: Preeclampsia/Eclampsia
Client Scenario
0800 Labor & Delivery Triage: A 32-year-old female at 36 weeks gestation presents with a
"splitting headache" that was not relieved by Acetaminophen. She reports seeing "bright
spots" in her vision and feeling nauseated. She notes her wedding ring no longer fits due to
finger swelling.
Physical Assessment:
Neurological: 3+ patellar reflexes (hyperreflexia); 2 beats of clonus noted in the
ankles.
Visual: Reports blurred vision and scotoma (blind spots).
Edema: 2+ pitting edema in the lower extremities and facial puffiness.
Vital Signs: BP 172/112, HR 88, RR 18, Temp 98.6°F. Fetal Heart Rate (FHR) is
145/min with moderate variability.
Item 1: Recognizing Cues (Visual/Reflexes)
Question: The nurse assesses the client's deep tendon reflexes (DTRs). Which diagram
correctly identifies the location for testing the patellar reflex and what a 4+ result would
indicate?
Correct Findings to Identify:
✅Hyperreflexia (3+ or 4+)
✅Positive Clonus (Rhythmic oscillations when the foot is dorsiflexed)
✅Severe Hypertension (SBP > 160 or DBP > 110)
✅Visual Disturbances (Scotoma)
Rationale: Hyperreflexia and clonus are signs of central nervous system (CNS) irritability. In
preeclampsia, high blood pressure leads to cerebral edema, which irritates the nerves and
puts the client at risk for a seizure (Eclampsia).
Item 2: Analyzing Cues (Labs)
