During a postpartum assessment, the nurse detects a positive ...

[kellyjaisingh]

During a postpartum assessment, the nurse detects a positive Homans' sign. A positive Homans' sign is elicited when the:
 
  a. Woman stands and feels pain in her foot
  b. Knee is slightly flexed, the foot is dorsiflexed, and pain is felt in her calf
  c. Knee is held flat, the foot rotated, and pain is felt in her calf
  d. Knee is flexed, the foot extended, and pain is felt in her calf

Question 2

Immediately after delivery, a woman begins to experience uncontrollable shivering. She asks the nurse what is happening to her. The nurse's most appropriate response would be:
 
  a. Don't worry, we will give you a pain medication, which will cause your shivering to stop.
  b. You are shivering because your body cooled. This is a normal response, and the shivering will stop shortly.
  c. Your health care provider will be here shortly to talk about your shivering.
  d. You are shivering because of the pain you experienced. The shivering will stop now that the pain is gone.

[Kaytorgator]

Answer to Question 1

ANS: B
By passive dorsiflexion of the feet, the nurse determines whether there is pain in the calf (a positive Homans' sign). Venous stasis, especially during late pregnancy, contributes to the risk of formation of blood clots in the lower extremities. A positive Homans' sign may be an early indicator of venous thrombosis and should be reported.

Answer to Question 2

ANS: B
Women often experience a shaking, uncontrollable chill immediately after delivery. The exact cause is unknown, but it may be related to a nervous system response or to vasomotor changes. The nurse should cover the mother with a warm blanket, offer a hot drink, and reassure her that the chill is a common, temporary episode following birth.