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. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.

B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.

C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.

D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.

A. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10 B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG C. A client who has Clostridium difficile and a temperature of 38.5° C(101.5°F) D. A client who has orthostatic hypotension and 4 pitting edema in the lower extremities

Correct Answer is B

Explanation

Rationale:

A. A client who has a complete femur fracture and reports a pain level of 7 on a scale from 0 to 10: Severe pain is significant and requires timely management, but it is not immediately life-threatening compared to acute cardiac events. Pain control should follow stabilization of critical conditions.

B. A client who has left shoulder pain and S-T elevation on a 12-lead ECG: ST-segment elevation indicates a possible acute myocardial infarction, which is a life-threatening emergency. Prompt assessment and intervention are crucial to prevent cardiac damage or death, making this the highest priority.

C. A client who has Clostridium difficile and a temperature of 38.5°C (101.5°F): Fever and infection require attention, but this client is currently stable compared with someone experiencing an acute myocardial infarction. Infection control and monitoring can follow stabilization of higher-priority emergencies.

D. A client who has orthostatic hypotension and 4+ pitting edema in the lower extremities: These findings indicate fluid imbalance and cardiovascular compromise, but they are not as immediately life-threatening as an acute STEMI. Monitoring and management should follow urgent cardiac care.

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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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Correct Answer is B

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