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
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.
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