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
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.
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