A nurse is teaching the guardian of a newborn about car seat safety.
Which of the following statements by the guardian indicates an understanding of the teaching?

Choice A rationale

Beginning ball-squeezing exercises is a correct instruction. These exercises, along with others like wall climbing, are essential to promote lymphatic drainage and restore range of motion in the arm on the affected side. Starting these early helps prevent the development of lymphedema, a common complication of mastectomy, by facilitating circulation and reducing fluid accumulation.

Choice B rationale

Wearing a bra with wire support is incorrect. Post-mastectomy, a client should be advised to wear a soft, supportive, and non-restrictive bra, preferably without underwire. Underwire can cause pressure and irritation on the incision site, potentially delaying healing and increasing the risk of lymphedema by compressing lymphatic vessels, which impedes the proper flow of lymph.

Choice C rationale

Avoiding using the affected arm for eating is incorrect. Gentle use of the affected arm for activities of daily living, such as eating and dressing, is encouraged early on to promote mobility and prevent stiffness. The key is to avoid strenuous activities and heavy lifting, but using the arm for routine tasks is beneficial for maintaining function and promoting recovery.

Choice D rationale

Using deodorant under the affected arm is incorrect. After a modified radical mastectomy, the client should be advised to avoid applying deodorant, lotions, or creams to the axilla on the surgical side. The skin in this area is often sensitive and prone to irritation, and these products can introduce bacteria, increasing the risk of infection and interfering with the healing process of the surgical site. .

Choice A rationale: Documentation of admission data should occur as soon as possible after the information is obtained. Waiting until the end of the shift to chart a summary increases the risk of forgetting critical details and delays the communication of important findings to the rest of the healthcare team.

Choice B rationale: The Patient Self-Determination Act requires healthcare facilities to ask clients upon admission if they have advance directives, such as a living will or a durable power of attorney for healthcare. This information must be clearly documented in the medical record to ensure the client's end-of-life wishes are respected.

Choice C rationale: The nursing process begins with assessment, not evaluation. Evaluation is the final step where the nurse determines if goals were met. Charting should follow the chronological order of the nursing process: assessment, diagnosis, planning, implementation, and finally, evaluation.

Choice D rationale: Registered nurses are responsible for the initial admission assessment, which includes the first set of vital signs. While assistive personnel can take routine vitals later, the nurse should personally obtain and document the baseline admission data to ensure accuracy and clinical oversight.