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 This symptom is outdated and not considered a definitive sign.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 C
Explanation
Choice A rationale
A 15-year-old, G3 P0020, although young, doesn't have an increased risk of uterine rupture related to prior surgical deliveries or other known factors.
Choice B rationale
A 22-year-old, G1 P0000 with eclampsia requires close monitoring for complications related to eclampsia but not specifically for uterine rupture.
Choice C rationale
A 25-year-old, G4 P3003 with a previous cesarean section is at increased risk for uterine rupture due to the scar from the prior surgery which could weaken under the stress of labor.
Choice D rationale
A 32-year-old, G2 P0100's history of a prior fetal demise does not specifically increase the risk of uterine rupture unless accompanied by other risk factors. .
Correct Answer is C
Explanation
Choice A rationale
Reporting abnormal findings to the obstetrician is unnecessary because an increase in the Bishop score from 4 to 10 indicates successful cervical ripening and readiness for labor
induction.
Choice B rationale
Placing the client on her side is not directly related to the assessment of cervical ripening or the Bishop score. It may be considered for comfort during labor.
Choice C rationale
Monitoring for the onset of labor is appropriate since the increase in the Bishop score to 10 suggests that the cervix is favorable for labor. Continuous monitoring is essential to detect
the onset and progression of labor.
Choice D rationale
Performing nitrazine analysis of amniotic fluid is not relevant to the assessment of cervical ripening or the Bishop score. This test is typically used to confirm the presence of amniotic
fluid in cases of suspected rupture of membranes.