A nurse is reinforcing teaching about travel with a client who is pregnant.Which of the following instructions should the nurse include?
Take a break and walk at least once every hour during long trips.
Wear the shoulder harness snug across your stomach.
Position the lap belt across your navel.
Move your car seat forward, close to the steering wheel.
The Correct Answer is A
Choice A rationale
Taking a break and walking at least once every hour during long trips helps improve circulation and reduces the risk of blood clots, which is particularly important during pregnancy.
Choice B rationale
Wearing the shoulder harness snug across the stomach is incorrect. The shoulder harness should be worn across the chest and between the breasts to avoid pressure on the abdomen.
Choice C rationale
Positioning the lap belt across the navel is incorrect. The lap belt should be placed under the belly, across the hips and pelvic bone, to avoid pressure on the uterus.
Choice D rationale
Moving the car seat forward, close to the steering wheel, is not recommended. Pregnant women should maintain a safe distance from the steering wheel to avoid injury in case of an accident.
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Correct Answer is B
Explanation
Choice A rationale
Placing the newborn supine and applying pressure to the soles of the feet is not the correct method to elicit the Babinski reflex. This action does not stimulate the appropriate nerve pathways involved in the reflex.
Choice B rationale
Stroking upward on the lateral aspect of the sole of the newborn’s foot is the correct method to elicit the Babinski reflex. This action stimulates the plantar reflex, causing the big toe to extend upward and the other toes to fan out.
Choice C rationale
Pulling the newborn up by the wrist from a supine position is used to elicit the traction response, not the Babinski reflex. The traction response involves the newborn flexing their arms and attempting to lift their head.
Choice D rationale
Touching the corner of the newborn’s mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex causes the newborn to turn their head toward the stimulus and open their mouth.
Correct Answer is D
Explanation
Choice A rationale
Auscultating the newborn’s bowel sounds is important for assessing gastrointestinal function, but it is not the first priority in managing a newborn with neonatal abstinence syndrome (NAS). Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.
Choice B rationale
Swaddling the newborn in blankets can help provide comfort and reduce excessive stimulation, which is beneficial for newborns with NAS. However, it is not the first priority. The primary focus should be on assessing and stabilizing the newborn’s vital signs.
Choice C rationale
Weighing the newborn’s wet diaper is important for monitoring fluid balance and hydration status, but it is not the first priority in managing NAS. Initial care should focus on stabilizing the newborn and addressing withdrawal symptoms.
Choice D rationale
Determining the newborn’s respiratory rate is the first priority in managing a newborn with NAS. Assessing and stabilizing the newborn’s vital signs, including respiratory rate, is crucial to ensure the newborn’s immediate health and safety.