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 This symptom is outdated and not considered a definitive sign.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 B
Explanation
Choice A rationale
Contraction duration less than 40 seconds doesn't define tachysystole. Tachysystole focuses on excessive frequency of contractions rather than their duration.
Choice B rationale
Contraction frequency of more than 5 in 10 minutes defines tachysystole. This condition indicates too frequent uterine activity, which can compromise fetal oxygenation.
Choice C rationale
Contraction intensity less than 80 mm Hg doesn't define tachysystole. Tachysystole is characterized by the number of contractions, not their intensity.
Choice D rationale
Resting tone less than 18 mm Hg is not related to the definition of tachysystole. Tachysystole concerns contraction frequency, not the resting tone of the uterus between contractions. .
Correct Answer is D
Explanation
Choice A rationale
Checking the blood sugar of a gestational diabetic is essential but not immediately life-threatening. Blood sugar levels should be monitored regularly throughout pregnancy for
diabetics to prevent complications. However, this does not represent an urgent priority when compared to the other options, which involve more immediate risks to life and health.
Choice B rationale
Assessing vaginal blood loss in a client recovering from a spontaneous abortion is crucial to monitor for hemorrhage or infection. Heavy bleeding could signal a serious complication
needing immediate intervention, though it is not the most immediate priority over monitoring fetal heart rate during active labor.
Choice C rationale
Monitoring the patellar reflexes of a client with pre-eclampsia without severe features can help in detecting early signs of progressing pre-eclampsia. While important, it is generally
not as critical as ensuring immediate fetal wellbeing, especially if reflexes do not present signs of worsening.
Choice D rationale
Checking the fetal heart rate in a client whose membranes have just ruptured is paramount. Rupture of membranes could lead to immediate complications such as umbilical cord
prolapse, leading to rapid fetal distress. Therefore, verifying fetal heart rate ensures that the fetus is not in immediate danger.