A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions.

What adverse effect does the nurse recognize as a result of this contraction pattern?

Choice C rationale
The apex of the heart is the most appropriate site to assess an infant’s heart rate. In infants, the apical pulse provides the most accurate assessment of heart rate. The apical pulse is located at the fifth intercostal space at the midclavicular line.
Choice A rationale
The carotid artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.
Choice B rationale
The brachial artery can be used to assess an infant’s heart rate, but it is typically used for blood pressure measurements rather than heart rate assessments.
Choice D rationale
The radial artery is not typically used to assess an infant’s heart rate. This site is more commonly used in adults and older children.

Choice A rationale
While an area of warmth can be a symptom of deep vein thrombosis (DVT), it is not the most specific or indicative symptom. DVT is a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs. The most common symptoms include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
However, these symptoms can also be associated with other conditions, making them less specific for DVT.
Choice B rationale
Nausea is not typically a symptom of deep vein thrombosis (DVT). The most common symptoms of DVT include swelling of the foot, ankle, or leg, usually on one side, cramping of the affected leg, severe leg pain, and skin on the affected area that is warmer than the skin on surrounding areas.
Choice C rationale
A cool-to-touch extremity is not typically a symptom of deep vein thrombosis (DVT). In fact, the skin over the affected area is often warmer than the skin on surrounding areas. Therefore, a cool-to-touch extremity would not typically be expected in a client with suspected DVT.
Choice D rationale
Calf tenderness when massaged is a common clinical finding in clients with deep vein thrombosis (DVT)2. DVT often causes pain and swelling in the affected leg, and this pain can be particularly noticeable or worsen when the calf is massaged or the client is standing or walking. Therefore, calf tenderness when massaged would be a clinical finding that a nurse should anticipate in a client being admitted with a suspected DVT.