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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Administer a continuous infusion of calcium gluconate: Calcium gluconate is not used for the management of preeclampsia or seizure prophylaxis. Magnesium sulfate is the medication of choice to prevent eclamptic seizures in clients with severe preeclampsia.

B. Place the client in the semi-Fowler's position: Semi-Fowler’s position does not optimize uteroplacental perfusion. Left lateral positioning is preferred to enhance blood flow to the uterus and improve maternal and fetal oxygenation.

C. Ensure bright lighting in the room: Bright lighting can increase stimulation and anxiety, which is not beneficial for a client at risk for seizures. A calm, low-stimulation environment is preferable to minimize seizure triggers.

D. Initiate seizure precautions: Clients with preeclampsia with severe features are at high risk for eclampsia, making seizure precautions essential. These include placing the bed in a low position, padding side rails, having oxygen and suction available, and monitoring closely for neurologic changes.

A. Abdomen B. Shoulder C. Neck D. Sternum

Correct Answer is D

Explanation

Rationale:

A. Abdomen: The abdominal skin may be loose due to age-related changes, weight fluctuations, or prior pregnancies, making it less reliable for assessing dehydration in older adults. Lifting skin here may give a false impression of skin turgor.

B. Shoulder: Skin over the shoulder can be affected by aging, sun exposure, or decreased subcutaneous tissue, which can distort the assessment of hydration status. It is not the preferred site for older adults.

C. Neck: The skin of the neck is thin and may show wrinkles or sagging unrelated to hydration. Assessing turgor here is less accurate in older clients and may overestimate skin elasticity changes due to aging.

D. Sternum: The skin over the sternum is relatively less affected by age-related changes and provides a more reliable site for assessing turgor in older adults. Lifting this area allows the nurse to evaluate hydration status more accurately without interference from natural skin laxity elsewhere.

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A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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