A postpartum woman who had a cesarean birth complains of warmth ...

[NClaborn]

A postpartum woman who had a cesarean birth complains of warmth and pain in one of her calves. Which assessment should the nurse perform as the priority?
 
  A.
  Bilateral calf circumference
  B.
  Homans' sign on both legs
  C.
  Lung sounds and oxygen saturation
  D.
  Pedal and popliteal pulses

Question 2

A nurse is caring for a patient on heparin for a deep vein thrombosis (DVT) and realizes that the patient has received an overdose of the medication. When contacting the physician, what orders does the nurse anticipate?
 
  A.
  Laboratory draw for PT/INR; administer protamine sulfate.
  B.
  Laboratory draw for PT/INR; administer vitamin K.
  C.
  Laboratory draw for aPTT; administer protamine sulfate.
  D.
  Laboratory draw for aPTT; administer vitamin K.

[gcook]

Answer to Question 1

ANS: A
Several clinical manifestations exist for DVT, including pain, calf tenderness, and leg swelling. The nurse can also assess warmth, redness, and possibly a palpable cord. The most accurate assessment is to measure and compare calf circumference; a 2-cm or greater increase on the painful side is an objective finding for DVT. Homans' sign is an assessment for DVT but may be inaccurate in as many as 50 of patients with DVT. Pulses may or may not be decreased, and the popliteal pulse is difficult to find in most patients. Because the patient did not complain of respiratory problems, listening to lung sounds and obtaining a pulse oximeter measurement is not the priority.

Answer to Question 2

ANS: C
Heparin therapy is monitored with the aPTT (activated partial thromboplastin time). The antidote for heparin is protamine sulfate. PT (prothrombin time) and INR (international normalized ratio) are used to monitor warfarin sodium therapy, although in many places INR is totally replacing the PT. Vitamin K is the antidote to warfarin.