The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? The client:
1. Reports she had this condition after her last pregnancy.
2. Develops pain and swelling in her left lower leg.
3. Appears anxious, and describes pressure in her chest.
4. Becomes upset that she can't go home yet.
3
Rationale:
1. This is a risk factor for the development of thrombophlebitis, but neither a predictor nor an indication of complications.
2. Development of bilateral thrombophlebitis is a complication, but not the top priority.
3. Anxiety and sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention.
4. Although the nurse provides client care with the aim of keeping clients satisfied and comfortable, becoming upset is a psychosocial issue, and far less important than development of a pulmonary embolus.
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