A nurse is caring for a child who has cystic fibrosis and requires postural drainage.

Which of the following actions should the nurse take?

The correct answer is B.

Choice A reason: Atrial fibrillation is characterized by a rapid, irregular heartbeat and an absence of distinct P waves on the ECG, which is not indicated by the information provided.

Choice B reason: First-degree AV block is indicated by a prolonged PR interval without affecting the overall heart rate, aligning with the client’s PR interval of 0.24 seconds.

Choice C reason: Premature ventricular contraction would show an abnormal QRS complex on the ECG, which is not mentioned in the scenario.

Choice D reason: Sinus bradycardia is defined by a heart rate less than 60 bpm, which does not apply here as the client’s heart rate is 69/min, within the normal range of 60-100 bpm.

The correct answer is B.

Assist the adolescent in applying for Medicaid.

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 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.