A nurse is caring for a client who has an acute exacerbation of chronic pain. Which of the following medications should the nurse anticipate administering for the client?

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.

Rationale:

A. Suction the client every 2 hr: Frequent suctioning can increase intracranial pressure due to stimulation of the airway and coughing reflex. Suctioning should be performed only when necessary and with careful monitoring of ICP, rather than routinely every 2 hours.

B. Maintain ICP at 20 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. An ICP of 20 mm Hg or higher indicates increased intracranial pressure and requires intervention. Planning to maintain ICP at this elevated level is unsafe and not appropriate for care planning.

C. Avoid overstimulation of the client: Minimizing noise, unnecessary procedures, and environmental stimuli helps prevent spikes in ICP. Overstimulation can increase cerebral metabolic demand and worsen intracranial hypertension, so this intervention supports ICP management and neurologic stability.

D. Keep the client in a supine position: Supine positioning can impair venous drainage from the brain, potentially increasing ICP. Elevating the head of the bed to 30 degrees while maintaining spinal precautions is preferred to promote venous outflow and reduce intracranial pressure.