A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?
Social relationship with peers
Plans for attending school while pregnant
Understanding of infant care
Current nutritional status
The Correct Answer is D
Rationale:
A. Social relationship with peers: Evaluating peer relationships helps determine the client’s emotional support system, which can influence stress levels and coping during pregnancy. However, this assessment does not pose an immediate impact on the physiologic wellbeing of the mother or fetus. It becomes more relevant after ensuring that no urgent health concerns are present.
B. Plans for attending school while pregnant: Exploring educational plans is important for long-term stability and preventing adverse socioeconomic outcomes. Although valuable for overall wellbeing, it is not an immediate safety concern. Educational planning should be addressed after assessing the pregnancy for factors that directly affect maternal–fetal health.
C. Understanding of infant care: Assessing knowledge of infant care helps identify educational needs before delivery and supports better neonatal outcomes. However, this is a future-oriented consideration and does not address the adolescent’s immediate health status. It becomes appropriate once urgent physiologic needs are evaluated.
D. Current nutritional status: Adolescents already have increased nutritional requirements for their own growth, and pregnancy further elevates these demands. Poor nutrition can lead to anemia, low birth weight, preterm birth, and delayed fetal growth, making it a priority assessment. Ensuring adequate maternal nutrition directly influences fetal development and reduces preventable complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Inability to concentrate: Hypoglycemia reduces glucose availability to the brain, leading to cognitive changes such as difficulty concentrating, confusion, or irritability. This neurologic symptom is an early and common indicator of low blood glucose.
B. Tremors: Trembling or shakiness occurs due to autonomic nervous system activation in response to low blood glucose. Catecholamine release stimulates muscle activity, making tremors a classic sign of hypoglycemia.
C. Acetone breath odor: Acetone or “fruity” breath is associated with diabetic ketoacidosis (DKA), a complication of hyperglycemia rather than hypoglycemia. It indicates fat metabolism due to insulin deficiency, not low blood glucose.
D. Diaphoresis: Profuse sweating is a sympathetic nervous system response to hypoglycemia. It often accompanies other adrenergic symptoms such as palpitations, anxiety, and tremors, signaling low blood sugar.
E. Polydipsia: Excessive thirst is a symptom of hyperglycemia and is not associated with hypoglycemia. It occurs when high blood glucose leads to osmotic diuresis and fluid loss.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Inactivated influenza vaccine: The inactivated influenza vaccine is safe during any trimester of pregnancy and helps protect both the mother and the fetus from influenza-related complications. It is routinely recommended for pregnant clients during flu season.
B. Varicella vaccine: The varicella vaccine is a live attenuated vaccine and is contraindicated during pregnancy because it poses a risk of fetal infection and congenital abnormalities. It should be administered before pregnancy or postponed until after delivery.
C. Tetanus, diphtheria, and acellular pertussis vaccine: The Tdap vaccine is recommended during pregnancy, ideally between 27 and 36 weeks gestation, to protect the newborn from pertussis. It is safe and provides passive immunity to the infant.
D. Inactivated polio vaccine: Inactivated polio vaccine (IPV) is safe during pregnancy and can be administered if the client is at risk for exposure or requires immunization. Live attenuated oral polio vaccine is contraindicated.
E. Rubella vaccine: The rubella vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of congenital rubella syndrome. Women should be screened for immunity prior to pregnancy and vaccinated if nonimmune before conception.
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