A child is admitted for nonorganic failure to thrive.
The nurse notes poor eye contact, listlessness, and rumination. What is the most appropriate nursing goal?

Choice A rationale

Acupressure involves applying pressure to specific points on the body, aiming to stimulate energy flow and relieve pain. While it can promote relaxation and analgesia by releasing endorphins, its direct effect on significantly reducing blood pressure and respiratory rate in acute anxiety may be less pronounced compared to methods emphasizing controlled breathing techniques.

Choice B rationale

Effleurage is a light, stroking massage, typically applied to the abdomen during contractions. This technique can distract from pain and promote relaxation by stimulating large nerve fibers, thereby reducing pain perception. However, its primary physiological impact is generally on pain modulation and comfort, rather than a direct, strong reduction in elevated blood pressure and respiratory rate.

Choice C rationale

The Bradley method, also known as "husband-coached childbirth," emphasizes natural childbirth, focusing on deep abdominal breathing, relaxation, and partner support. While it promotes a calm environment and can reduce overall stress, its specific techniques for immediate physiological regulation of acutely elevated blood pressure and erratic respirations may not be as direct as methods specifically teaching controlled breathing.

Choice D rationale

The Lamaze method focuses on controlled breathing and relaxation techniques during labor. These techniques, particularly patterned breathing, directly influence the autonomic nervous system by increasing vagal tone, which can lead to a decrease in heart rate and respiratory rate, thereby lowering blood pressure and promoting a sense of calm during periods of anxiety.

Choice E rationale

Yoga incorporates physical postures, breathing exercises (pranayama), and meditation. While highly effective for long-term stress reduction and improving cardiovascular health, its immediate application in a laboring client experiencing acute anxiety with elevated vital signs might be less practical for immediate physiological regulation compared to targeted breathing methods like Lamaze.

Choice A rationale

This choice is incorrect because Naegele's Rule involves adding seven days to the first day of the last menstrual period and then subtracting three months. Starting with September 17, adding seven days yields September 24. Subtracting three months from September 24 results in June 24, which is not the correct estimated delivery date according to the rule.

Choice B rationale

This choice is incorrect because applying Naegele's Rule requires a precise calculation. If the first day of the last menstrual period was September 17, adding seven days gives September 24. Subtracting three months from September 24 would result in June 24, not June 10, thus indicating an error in calculation for this option.

Choice C rationale

This choice is incorrect as it does not align with the application of Naegele's Rule. The rule specifies adding seven days to the LMP and subtracting three months. Starting from September 17, adding seven days brings it to September 24. Subtracting three months from September 24 mathematically leads to June 24, making June 20 an inaccurate calculation.

Choice D rationale

This choice is correct because Naegele's Rule is applied by adding seven days to the first day of the last menstrual period and then subtracting three months. With a last menstrual period of September 17, adding seven days results in September 24. Subtracting three months from September 24 accurately yields June 24 of the following year as the estimated date of delivery.