Sunday, December 24, 2023

A postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis.. Palpate for pedal pulses



A postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis.

Which of the following nursing actions is indicated in assessing for thrombophlebitis?
  • a) Ask the client to ambulate and assess for the presence of pain.
  • b) Ask the client about pain in the calf area.
  • c) Palpate for pedal pulses.
  • d) Assess for the presence of vaginal hematoma.

The correct answer is: b) Ask the client about pain in the calf area.

Here's why:
  • Thrombophlebitis is a condition characterized by inflammation and blood clot formation in a vein. It is a common complication after delivery, especially in women who have had cesarean sections or who have other risk factors such as obesity or immobility.
  • Pain in the calf area is a common symptom of thrombophlebitis in the leg. The pain may be described as sharp, throbbing, or aching, and it may be worse when the client walks or flexes the foot.
  • While the other actions listed may be relevant to postpartum care, they are not specifically related to assessing for thrombophlebitis.

Here's why the other options are less relevant:

a) Ask the client to ambulate and assess for the presence of pain:

While ambulating can help to prevent thrombophlebitis, it is not the most specific way to assess for the condition. Pain is a more direct indicator.

c) Palpate for pedal pulses:

This is a routine part of a postpartum assessment, but it is not specific to thrombophlebitis. Diminished or absent pulses could indicate a more serious condition called deep vein thrombosis (DVT).

d) Assess for the presence of vaginal hematoma:

This is another potential complication after delivery, but it is not related to thrombophlebitis.

Therefore, the most specific and relevant action to assess for thrombophlebitis in a postpartum client is to ask the client about pain in the calf area.