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In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?

A.

The woman complains of numbness in the toes and heel of one foot.

B.

The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed.

C.

The veins in the ankle of one of the woman's legs are spider-like and purple.

D.

The calf of one of the woman's legs is swollen, red, and warm to touch.

Answer and Explanation

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 This symptom is outdated and not considered a definitive sign.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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View Related questions

Correct Answer is C

Explanation

Choice A rationale

While maternal lacerations are a risk during childbirth, they are not the greatest risk in cases of fetal dystocia. The focus is primarily on fetal wellbeing.

Choice B rationale

Fetal injury such as bruising can occur with dystocia, but the primary concern is the potential for severe, life-threatening complications.

Choice C rationale

Neonatal asphyxia related to prolonged labor is the greatest risk with fetal dystocia. Prolonged labor can lead to decreased oxygen supply to the fetus, causing asphyxia and

potential brain injury.

Choice D rationale

Increased consideration for a cesarean delivery is a possible outcome of fetal dystocia, but it is a management decision rather than a direct risk to the baby’s immediate health.

Correct Answer is B

Explanation

Choice A rationale

Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on frequency, not duration, of contractions over a specific time frame.

Choice B rationale

Contraction frequency of more than 5 in 10 minutes defines tachysystole. This frequency indicates excessive uterine activity, requiring intervention to prevent fetal distress.

Choice C rationale

Contraction intensity less than 80 mm Hg does not define tachysystole. Intensity relates to contraction strength, but tachysystole is about frequency exceeding the normal range.

Choice D rationale

Resting tone less than 18 mm Hg isn't part of tachysystole's definition. Tachysystole pertains to contraction frequency, not resting tone, which measures uterine relaxation between contractions.

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