A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac.

Which of the following interventions should be incorporated into the care plan?

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.

Choice A rationale
Vomiting is not a common side effect of epidural anesthesia. Nausea can occur, but it is usually associated with the opioids used in the epidural, not the epidural itself.
Choice B rationale
Tachycardia, or a rapid heart rate, is not a typical side effect of epidural anesthesia. In fact, an epidural can sometimes cause a drop in heart rate, known as bradycardia.
Choice C rationale
Hypotension, or low blood pressure, is a common side effect of epidural anesthesia. The medication used in the epidural can cause blood vessels to relax, which can lower blood pressure.
Choice D rationale
Respiratory depression is not a common side effect of epidural anesthesia. The medication used in an epidural primarily affects the nerves in the lower body, so it does not typically impact breathing. Digoxin Digoxin Explore