NCLEX-RN® OB Complications: Preeclampsia, Placenta Problems, Hemorrhage, and Emergency Signs
High-risk obstetric content for the NCLEX-RN®: preeclampsia vs. eclampsia warning signs, placenta previa vs. abruptio, postpartum hemorrhage interventions, and when to call the provider.
The big picture
OB complications are among the highest-stakes scenarios in nursing — they involve two patients simultaneously (mother and fetus) and can deteriorate rapidly. The NCLEX-RN® tests recognition of danger signs, priority nursing actions, and the critical difference between life-threatening conditions that look similar on the surface. Knowing whether abdominal pain is preeclampsia, abruption, or rupture can be the difference between a rapid intervention and a catastrophic outcome.
Hypertensive disorders of pregnancy
Classifications
| Disorder | Criteria |
|---|---|
| Gestational hypertension | BP ≥ 140/90 on two occasions ≥ 4 h apart after 20 weeks; no proteinuria |
| Preeclampsia | HTN after 20 weeks + proteinuria (≥ 300 mg/24 h or protein:creatinine ratio ≥ 0.3) OR signs of severe features without proteinuria |
| Preeclampsia with severe features | BP ≥ 160/110 OR any of the severe features below |
| Eclampsia | Preeclampsia + seizure (not attributable to another cause) |
| HELLP syndrome | Hemolysis, Elevated Liver enzymes, Low Platelets |
| Superimposed preeclampsia | Chronic hypertension + new proteinuria after 20 weeks |
Severe features of preeclampsia — NCLEX® must-knows
Any one of the following makes preeclampsia "severe":
- BP ≥ 160/110 on two readings ≥ 4 h apart while on bedrest
- Platelet count < 100,000/mm³
- Impaired liver function (LFTs > twice normal) or right upper quadrant/epigastric pain
- Progressive renal insufficiency (creatinine > 1.1 mg/dL or doubling)
- Pulmonary edema
- New-onset headache unresponsive to medication
- Visual disturbances (scotoma, blurred vision, photophobia)
Magnesium sulfate — priority nursing management
Magnesium sulfate (MgSO₄) is used for seizure prevention in preeclampsia and seizure treatment in eclampsia. It is also used for preterm labor tocolysis.
Toxicity is the major concern:
| Finding | Significance |
|---|---|
| Respiratory rate < 12 breaths/min | MgSO₄ toxicity — STOP infusion |
| Loss of deep tendon reflexes (DTRs) | Early toxicity sign — first to go |
| Urine output < 25–30 mL/hr | Impaired excretion → toxicity accumulates |
| Serum Mg level > 9 mEq/L | Cardiac arrest risk |
Before each assessment, check:
- DTRs (patellar reflex must be present)
- Respiratory rate (must be ≥ 12)
- Urine output (must be ≥ 25–30 mL/hr)
Antidote for MgSO₄ toxicity: Calcium gluconate 10% — always keep at the bedside, drawn up and ready.
Eclampsia (seizure in pregnancy)
During a seizure:
- Do not leave the patient
- Protect from injury (side rails padded)
- Turn to left lateral position (prevents aspiration + relieves aortic compression)
- Administer oxygen
- MgSO₄ IV bolus as ordered (if not already on it) to stop seizure
- Notify provider immediately
- Prepare for delivery — eclampsia frequently prompts expedited delivery
HELLP syndrome
A severe variant of preeclampsia with:
- Hemolysis (falling Hgb, abnormal peripheral smear)
- Elevated Liver enzymes (AST/ALT)
- Low Platelets (< 100,000/mm³)
Signs: right upper quadrant or epigastric pain, nausea/vomiting, malaise, jaundice. HELLP can occur without classic preeclampsia signs — always suspect in any pregnant woman with RUQ pain.
Management: Delivery is the only cure. Supportive care includes: platelets if < 20,000 before delivery, corticosteroids to improve platelets and lung maturity, blood products if hemorrhaging.
Placental complications
Placenta previa vs. placental abruption — the classic NCLEX® comparison
| Feature | Placenta previa | Placental abruption |
|---|---|---|
| Cause | Placenta implanted over/near cervical os | Premature separation of normally implanted placenta |
| Bleeding | Painless, bright red vaginal bleeding | Painful — sudden, severe, constant abdominal pain; may have dark red vaginal bleeding |
| Pain | None | Severe abdominal pain (board-like rigidity) |
| Uterus | Soft | Rigid, tender, board-like |
| Fetal heart tones | Usually stable | Variable — can deteriorate rapidly if large abruption |
| Vaginal exam | CONTRAINDICATED — triggers catastrophic hemorrhage | Not contraindicated but use caution |
| Management | C-section if complete; bed rest; no vaginal exams | Stabilize, monitor fetus, prepare for C-section |
NCLEX® key: Placenta previa = painless bright red bleeding; never do a vaginal exam. Placental abruption = painful, rigid uterus.
Uterine rupture
Rupture of the uterus, usually along a previous cesarean scar. A life-threatening emergency.
Signs:
- Sudden cessation of contractions (previously strong contractions stop suddenly)
- Severe abdominal pain — "tearing" sensation
- Loss of fetal station (presenting part recedes upward)
- Fetal heart rate becomes non-reassuring (bradycardia, late decels)
- Signs of maternal shock (hypotension, tachycardia)
Action: Call provider/OB immediately. Prepare for emergency C-section. IV access, blood products on standby.
Postpartum hemorrhage (PPH)
PPH is the leading cause of maternal mortality worldwide. It is defined as blood loss > 1,000 mL (or any amount causing hemodynamic instability) after delivery.
The 4 Ts — causes of PPH
| Cause | Mechanism |
|---|---|
| Tone (most common — 80% of PPH) | Uterine atony — the uterus doesn't contract after delivery |
| Trauma | Lacerations of vagina, cervix, or uterus |
| Tissue | Retained placental fragments preventing uterine contraction |
| Thrombin | Coagulopathy (DIC, HELLP, inherited disorder) |
Priority assessment for PPH
- Uterine tone: Palpate fundus — boggy (soft) uterus = atony = most common cause
- Estimate blood loss: count pads, weigh underpads (1 gram = 1 mL)
- Vital signs: HR and BP are late indicators in young, healthy patients — tachycardia is often the earliest sign
- Skin and perfusion: pallor, diaphoresis, cool extremities
Management of uterine atony
- Uterine massage (fundal massage): Firm circular massage on the fundus — most immediate nursing action for a boggy uterus
- Oxytocin (Pitocin): IM or IV infusion — uterotonic of choice
- Methylergonovine (Methergine): IM injection — contraindicated in hypertensive patients (causes vasoconstriction)
- Misoprostol: Can be given rectally or sublingually
- Carboprost (Hemabate): Prostaglandin F2α — contraindicated in asthma (causes bronchospasm)
- Surgical interventions if medical management fails: B-Lynch suture, uterine artery ligation, hysterectomy
Ectopic pregnancy
Implantation outside the uterus — most commonly in the fallopian tube. A life-threatening emergency if the tube ruptures.
Signs and symptoms:
- Amenorrhea (missed period)
- Unilateral lower abdominal/pelvic pain
- Vaginal spotting
- Positive pregnancy test
- Signs of rupture: Sudden severe pain, shoulder pain (diaphragm irritation from intraperitoneal bleeding), shock
NCLEX® alert: Shoulder pain in a pregnant patient is a red flag for intraperitoneal bleeding — refer immediately.
Management: Methotrexate (if unruptured and eligible) or surgical management (salpingectomy/salpingostomy).
Preterm labor
Labor before 37 completed weeks of gestation. Risk factors include: prior preterm birth, multiple gestation, cervical insufficiency, infection, smoking.
Tocolytic medications — stop preterm contractions
| Drug | Class | Key concern |
|---|---|---|
| Terbutaline | Beta-2 agonist | Maternal tachycardia, tremors, palpitations; monitor HR |
| Nifedipine | Calcium channel blocker | Hypotension; maternal HR changes |
| Indomethacin | NSAID (prostaglandin inhibitor) | Premature closure of ductus arteriosus — not used > 32 weeks |
| Magnesium sulfate | Electrolyte/tocolytic | Also neuroprotective for fetal brain — used < 32 weeks |
Antenatal corticosteroids — fetal lung maturity
Betamethasone or dexamethasone IM (two doses, 24 hours apart) are given at 24–34 weeks when preterm delivery is anticipated. Accelerates fetal lung maturity (surfactant production), reducing risk of respiratory distress syndrome (RDS).
NCLEX® clinical judgment focus
OB complication questions always prioritize:
- Fetal status — is the baby tolerating whatever is happening?
- Maternal hemodynamic stability — is the mother going into shock?
- Identify the complication correctly — the correct intervention depends entirely on the right diagnosis
"Which action does the nurse take first?" in OB emergencies:
- Cord prolapse → push presenting part up manually while calling for help
- Eclamptic seizure → left lateral position + call for help + O₂
- Boggy uterus → fundal massage immediately
- MgSO₄ toxicity (RR < 12 or no DTRs) → stop the infusion + calcium gluconate
FAQ
What is the most important thing to check before administering magnesium sulfate?
Check respiratory rate, deep tendon reflexes, and urine output. If RR < 12, DTRs are absent, or urine output < 25 mL/hr, hold the infusion and notify the provider. Calcium gluconate (the antidote) must be at the bedside before starting MgSO₄.
Why is a vaginal exam contraindicated with placenta previa?
The placenta is implanted over or near the cervical os. A vaginal exam can disrupt the placenta and cause massive, uncontrollable hemorrhage — potentially lethal. Diagnosis is confirmed by ultrasound, and delivery is by cesarean section.
How quickly can a postpartum hemorrhage become life-threatening?
A woman can lose over 1,000 mL of blood in minutes with uterine atony. Because pregnancy-related blood volume expansion allows compensation for a time, vital sign changes may be delayed. Tachycardia and pallor are often the earliest visible signs. Never wait for hypotension to intervene.
What is the difference between eclampsia and seizures from another cause?
Eclampsia is a seizure occurring in a woman with preeclampsia, typically after 20 weeks of gestation or up to 6 weeks postpartum. It requires magnesium sulfate — not phenytoin or benzodiazepines as first-line. If a woman has a seizure during pregnancy without prior preeclampsia signs, other causes must be ruled out (epilepsy, stroke, metabolic).
When should preterm labor be treated with steroids?
Betamethasone or dexamethasone is given at 24–34 weeks of gestation (some guidelines extend to 36 weeks for late preterm births in certain scenarios) when preterm delivery is anticipated within 7 days. The two doses given 24 hours apart accelerate fetal lung maturity and significantly reduce RDS, IVH, and neonatal mortality.
Key takeaways
- Preeclampsia: HTN + proteinuria after 20 weeks. Severe features: BP ≥ 160/110, platelets < 100,000, RUQ pain, vision changes. MgSO₄ for seizure prevention — check RR, DTRs, urine output; antidote = calcium gluconate.
- HELLP: H + EL + LP. RUQ pain + nausea + falling platelets. Delivery is the cure.
- Previa vs. abruption: Previa = painless bright red + no vaginal exam. Abruption = painful + board-like uterus.
- PPH: 4 Ts. Boggy uterus → massage immediately. Oxytocin first. Methergine contraindicated in HTN. Carboprost contraindicated in asthma.
- Cord prolapse: Manual elevation of presenting part + Trendelenburg + O₂ + C-section.
Sources: NCSBN NCLEX-RN® 2023 Test Plan; CDC Severe Maternal Morbidity Indicators; AHRQ Obstetric Hemorrhage Patient Safety Bundle.
See also:
- NCLEX-RN® Maternity Nursing Guide
- NGN Case Study: Severe Preeclampsia
- NCLEX-RN® Newborn Care
- Emergency Nursing and Triage
- NCLEX-RN® Lab Values Guide
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