A client is concerned about needing a blood transfusion after delivery due to the blood loss in delivery. The nurse explains that blood volume increases during pregnancy. Which of the following is the correct percentage of increased blood volume during pregnancy that the nurse should explain to the client?
10% - 15%.
20% - 30%.
40% - 50%.
65% - 75%. .
The Correct Answer is C
Choice A rationale
A 10% to 15% increase in blood volume during pregnancy is too low compared to the average physiological changes that occur.
Choice B rationale
A 20% to 30% increase in blood volume is also below the expected range of increase during pregnancy.
Choice C rationale
Blood volume typically increases by 40% to 50% during pregnancy. This significant increase supports the demands of the growing fetus and placenta and prepares the mother's body for the blood loss that occurs during delivery.
Choice D rationale
A 65% to 75% increase is an overestimate. Such an extensive increase would be abnormal and is not typical in healthy pregnancies.
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Correct Answer is B
Explanation
Choice A rationale
Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the
head is turned and the opposite arm bending at the elbow, resembling a fencing position.
Choice B rationale
Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing
the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.
Choice C rationale
Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe
moving upward or toward the top surface of the foot and the other toes fanning out.
Choice D rationale
Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object
placed at the base of the toes. .
Correct Answer is C
Explanation
Choice A rationale
Sneezing is a reflex action to clear the nasal passages and is not a feeding cue. It does not indicate hunger but is more likely related to environmental irritants or the baby adjusting to breathing air.
Choice B rationale
Moving legs in a bicycle motion is a common newborn reflex that is associated with general activity or discomfort, rather than a specific signal of hunger. This movement is typically seen during periods of wakefulness or while the baby is trying to soothe themselves.
Choice C rationale
Putting their hand to their mouth is a well-recognized hunger cue in newborns. This behavior often precedes crying and indicates that the baby is ready to feed. It's a self-soothing mechanism that also signals hunger.
Choice D rationale
Extending both arms to the side of their body is more related to the Moro reflex, which is a startle reflex in response to a sudden movement or noise. It is not associated with feeding cues or hunger.