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 D
Explanation
Choice A rationale
White blood cell count is not an indicator of anemia. It measures immune function and can indicate infection or inflammation.
Choice B rationale
Urine specific gravity does not identify the risk for pregnancy-induced hypertension. It measures the concentration of urine and can indicate hydration status.
Choice C rationale
Sedimentation rate does not check for signs of cancer. It measures inflammation in the body and can indicate various conditions.
Choice D rationale
Platelet count identifies if the client is at risk for bleeding. Low platelet levels can indicate a higher risk of bleeding and are important to monitor during pregnancy.
Correct Answer is D
Explanation
Choice A rationale
Serum bilirubin is not the priority test for hyperemesis gravidarum. It is more relevant for assessing liver function and jaundice.
Choice B rationale
Liver enzymes may be elevated in hyperemesis gravidarum, but they are not the priority test. The primary concern is dehydration and electrolyte imbalance.
Choice C rationale
A CBC can provide information on the client’s overall health, but it is not the priority test for hyperemesis gravidarum. The focus should be on assessing hydration status.
Choice D rationale
Urinalysis for ketones is the priority test because it helps assess the severity of dehydration and malnutrition. The presence of ketones indicates that the body is breaking down fat for energy, which is a sign of inadequate caloric intake.