A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?

This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention. Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism. The nurse should assess this client first and notify the provider.

Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is well- controlled and does not need urgent attention.

The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.

Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.

The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A.

Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.

Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.

The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.

This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and the postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.