8. A 37-year-old client, who is a multipara, delivered an 8-pound, 9-ounce infant about 24 hours ago. A nurse is performing a routine assessment of the client's lower extremities for the possible development of thrombophlebitis. For which sign should the nurse assess?
Test-Taking Tip
Three of the options (Answers 1, 3, and 4) are pregnancy-related conditions. Eliminate those options since the focus is on postpartum.
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
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Answer 1 is incorrect because Chadwick's sign is a bluish discoloration of the cervix and vagina, classically associated with pregnancy. Answer 2 is correct because Homans' sign is pain in the back of the calf or knee when the foot is dorsiflexed, and is typically associated with thrombosis in veins of the calf. Answer 3 is incorrect because Hegar's sign is a softening of the lower uterine segment just above the cervix, seen as a probable sign of pregnancy. Answer 4 is incorrect because Goodell's sign is the softening of the cervix seen as early as 6 weeks' gestation and is a probable sign of pregnancy.
