In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
The woman complains of numbness in the toes and heel of one foot.
The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed.
The veins in the ankle of one of the woman's legs are spider-like and purple.
The calf of one of the woman's legs is swollen, red, and warm to touch.
The Correct Answer is D
Choice A rationale
Numbness in the toes and heel might suggest nerve involvement but is not a typical sign of deep vein thrombosis (DVT), which involves the veins, not nerves.
Choice B rationale
Pain relieved by dorsiflexion (positive Homan's sign) is not reliable for diagnosing DVT. This symptom is outdated and not considered a definitive sign.
Choice C rationale
Spider-like and purple veins suggest superficial varicose veins, not deep vein thrombosis, which affects deeper veins and presents differently.
Choice D rationale
Swelling, redness, and warmth in the calf are classic signs of DVT due to the inflammation and obstruction of deep veins. These symptoms should prompt immediate medical evaluation and intervention. .
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Correct Answer is A
Explanation
Choice A rationale
Postpartum psychosis poses significant risks to both the mother and her infant. The mother may have impaired judgment, hallucinations, or delusions, making it unsafe for her to be
left alone with her baby.
Choice B rationale
Symptoms of postpartum psychosis can persist for several weeks to months without appropriate treatment. Immediate and ongoing intervention is crucial to manage the condition.
Choice C rationale
Clinical response to medications for postpartum psychosis can vary, but with proper treatment, many clients show significant improvement. It is not accurate to state that the
response is usually poor.
Choice D rationale
While monitoring vitals may be part of overall care, it is not the most critical teaching point. Ensuring the mother is never left alone with her infant is essential to prevent potential
harm.
Correct Answer is B
Explanation
Choice A rationale
Magnesium sulfate is not given to increase diuresis; this is not its primary effect and is incorrect in the context of treating preeclampsia.
Choice B rationale
Magnesium sulfate is administered to prevent seizures in patients with preeclampsia. It acts as a central nervous system depressant and helps in preventing eclampsia.
Choice C rationale
Although magnesium sulfate may have a mild effect on reducing blood pressure due to its vasodilatory properties, this is not its primary purpose in the management of preeclampsia.
Choice D rationale
Magnesium sulfate is not used to slow the process of labor; its main role is seizure prophylaxis in preeclampsia.