Question

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?

A. Assessing the client's blood pressure
B. Massaging the client's legs
C. Encouraging ankle and foot exercises
D. Checking for unilateral leg swelling and tenderness

Answer 1

In assessing for thrombophlebitis, the indicated nursing action is to check for unilateral leg swelling and tenderness, while avoiding leg massages. Ankle and foot exercises are encouraged, and compression stockings may be used as a prevention strategy.

Step-by-step explanation:

When assessing a postpartum client at risk for thrombophlebitis, it is important to monitor for signs that could indicate the presence of a clot in a vein, particularly in the legs. The nurse should refrain from massaging the client's legs, as this could potentially dislodge a clot. Instead, the nurse should check for unilateral leg swelling and tenderness, which are common signs of thrombophlebitis. While assessing blood pressure is a routine part of postpartum care, it is not specifically indicative of thrombophlebitis. Encouraging ankle and foot exercises can help with circulation and potentially reduce the risk of clot formation. Compression stockings may be advised to provide increased pressure to help the veins return blood to the heart and can be considered a preventive measure against thrombophlebitis.