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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 A

Explanation

Choice A rationale

Placing the retainer clip at the level of the baby’s armpits is the correct position for the clip. This ensures that the harness straps are positioned correctly over the baby’s shoulders, providing optimal protection in the event of a crash.

Choice B rationale

Placing the baby in the car seat at a 90-degree angle is incorrect. Newborns should be placed in a rear-facing car seat at an angle of approximately 45 degrees to ensure their airway remains open and to provide proper support for their head and neck.

Choice C rationale

Turning the car seat to face forward when the baby weighs 15 pounds is not recommended. Babies should remain in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age.

Choice D rationale

Placing a thick, soft pad behind the baby’s back is not recommended. Additional padding can interfere with the proper fit of the harness and reduce the effectiveness of the car seat in protecting the baby during a crash.

Correct Answer is B

Explanation

Choice A rationale

Acrocyanosis is a common finding in newborns and is not a sign of dehydration. It usually resolves on its own.

Choice B rationale

A capillary refill time greater than 3 seconds can indicate dehydration in a newborn. It suggests poor perfusion and fluid status.

Choice C rationale

Voiding four times in the past 24 hours is within the normal range for a newborn and does not indicate dehydration.

Choice D rationale

A flat soft anterior fontanel is normal in newborns and does not indicate dehydration. A sunken fontanel would be a sign of dehydration.

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