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A nurse is reinforcing teaching about travel with a client who is pregnant.Which of the following instructions should the nurse include?

A.

Take a break and walk at least once every hour during long trips.

B.

Wear the shoulder harness snug across your stomach.

C.

Position the lap belt across your navel.

D.

Move your car seat forward, close to the steering wheel.

Answer and Explanation

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

Hypertension is not a common adverse effect of epidural anesthesia. In fact, epidurals can cause hypotension due to the blockade of sympathetic nerves.

Choice B rationale

Tachypnea is not typically associated with epidural anesthesia. Common side effects include low blood pressure and headache.

Choice C rationale

Tachycardia is not a common adverse effect of epidural anesthesia. More common side effects include low blood pressure and urinary retention.

Choice D rationale

Fever is a known adverse effect of epidural anesthesia. It can occur due to the body’s response to the epidural procedure.

Correct Answer is A

Explanation

Choice A rationale

A positive Babinski reflex is characterized by the fanning out of the toes and the upward movement of the big toe when the sole of the foot is stroked. This reflex is normal in infants up to 2 years old and indicates an immature central nervous system. The presence of this reflex in older children or adults can indicate neurological issues.

Choice B rationale

Curling in of the toes when the sole of the foot is stroked is indicative of the plantar grasp reflex, not the Babinski reflex. The plantar grasp reflex is a different neurological response and does not indicate the same neurological development as the Babinski reflex.

Choice C rationale

No response when the sole of the foot is stroked could indicate a lack of neurological response or an issue with the sensory or motor pathways. This is not characteristic of a positive Babinski reflex and could be a sign of neurological impairment.

Choice D rationale

The big toe bending down when the sole of the foot is stroked is a normal response in older children and adults, known as the plantar reflex. This response indicates a mature central nervous system and is not characteristic of a positive Babinski reflex in infants.

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