Which of the following signs or symptoms would a nurse note if superficial venous thrombosis were present in a mother who delivered a healthy infant by cesarean section?

1. A

   Enlarged and hardened veins

2. B

   Coolness of the calf area

3. C

   Palpable dorsalis pedis pulse

4. D

   Paleness of the calf area

Appeared in: DSSSB -28 August 2019 (Shift-2)

Explanation

• Superficial venous thrombosis (SVT) is characterized by inflammation and clotting within a superficial vein.
• This process causes the vein to become firm, tender, and palpable as a 'cord-like' structure.
• Associated signs include localized redness (erythema) and warmth due to the inflammatory response.
• The vein may also appear visibly enlarged or prominent.

Why Other Options Were Wrong

• Option B: Coolness of the calf is a classic sign of arterial insufficiency, not venous thrombosis. Venous inflammation typically causes warmth.
• Option C: A palpable dorsalis pedis pulse is a normal finding that indicates adequate arterial blood flow to the foot. It does not provide information about the status of the superficial venous system.
• Option D: Paleness (pallor) of the calf is a sign of reduced arterial blood flow (ischemia). Venous congestion and inflammation, as seen in SVT, typically cause redness or a dusky discoloration.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Clinical signs of Superficial Venous Thrombosis (SVT) to guide bedside assessment, documentation, and the next nursing action.
• Nurses must be able to differentiate between venous and arterial circulatory problems, as the management is vastly different and misdiagnosis can lead to severe complications.
• Postpartum and postoperative patients are at high risk for thromboembolic events due to hypercoagulability and immobility. Daily leg assessment is a critical nursing responsibility.
• Patient education on signs of thrombosis and the importance of early ambulation is a key component of preventing DVT and SVT after surgery or delivery.

How to Approach the Question

• First, identify the core concept of the question: the clinical signs of 'superficial venous thrombosis'.
• Recall the pathophysiology of SVT: it's an inflammatory process involving a clot in a vein near the skin. Inflammation causes redness, warmth, pain, and hardening.
• Evaluate each option against this understanding.
• Option A ('Enlarged and hardened veins') directly matches the description of an inflamed, thrombosed vein (a 'palpable cord').
• Options B ('Coolness') and D ('Paleness') are signs of poor arterial blood flow, the opposite of what's expected with venous inflammation. Eliminate these.
• Option C ('Palpable dorsalis pedis pulse') is a normal arterial assessment finding and is not specific to a venous problem. Eliminate this as it's not a sign of SVT.

Concept Tested & Keywords

• Concept Tested: Clinical signs of Superficial Venous Thrombosis (SVT)
• Stem keywords: superficial venous thrombosis, cesarean section, signs or symptoms
• Lead-in keywords: Which of the following
• Clinical cues: Patient is post-cesarean section, which is a risk factor for thromboembolic events.
• Negative lead-in flag: false

Question ID

QLTmBl8SFvVRabdSEAxdkM

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 77-79