A nurse is caring for an adolescent who recently found out that they are unexpectedly pregnant. Which of the following statements indicates that the client is emotionally prepared for pregnancy?

A. Completing an incident report is required for tracking falls and improving safety measures, but it is not the first priority. The nurse must first assess the client to determine if immediate medical intervention is needed. Delay in assessment could lead to unrecognized injuries or complications. Incident reports are also not part of the medical record and should be completed after client care. Ensuring client stability always takes precedence over documentation.
B. Measuring vital signs is the priority because it helps identify any immediate complications from the fall, such as hypotension, pain, or neurological impairment. A sudden drop in blood pressure could indicate shock, while tachycardia may suggest distress or injury. Checking for changes in mental status, pain levels, and potential fractures ensures timely intervention. If abnormalities are found, further evaluation or treatment can be initiated promptly. Early assessment prevents worsening conditions and guides further actions.
C. Documenting the fall in the client's medical record is necessary for continuity of care but should be done after assessing and stabilizing the client. Medical documentation includes details about the fall, findings from the assessment, and any interventions provided. However, delaying assessment to document first could result in missed critical signs of injury. Proper documentation supports quality care but is secondary to ensuring the client’s immediate well-being. The nurse should prioritize physical assessment before recording the incident.
D. Notifying the provider is important, especially if the client has sustained injuries, is in pain, or has abnormal vital signs. However, calling the provider before performing an assessment can lead to incomplete or inaccurate reporting. The provider will need specific details about the client's condition, including neurological status, hemodynamics, and any visible injuries. Conducting an assessment first ensures that the provider receives the most relevant and useful information. Immediate assessment allows for timely intervention and prevents unnecessary delays in care.

A. Diminished pulses on the affected extremity. Reduced pulses suggest impaired circulation, which may indicate compartment syndrome, a serious complication where increased pressure restricts blood flow. Without prompt intervention, this can lead to tissue damage or limb loss. The nurse should assess for additional signs such as pallor, paresthesia, and unrelieved pain and notify the provider immediately.
B. One fingerbreadth of space between the cast and the skin. This is an expected finding, as having a small space between the cast and skin allows for proper circulation and prevents excessive pressure that could lead to skin breakdown. The cast should be snug but not too tight to allow for swelling that may occur after injury or surgery. However, this does not require immediate intervention.
C. Client report of muscle spasms of the left leg. Muscle spasms are common in clients with immobilized limbs due to muscle fatigue, positioning, or nerve irritation. While uncomfortable, they do not indicate an emergency. The nurse can suggest gentle repositioning, relaxation techniques, or prescribed muscle relaxants to alleviate discomfort.
D. Ecchymosis on the inner left thigh. Bruising is a normal response to trauma and does not necessarily indicate a severe complication. It should be monitored for changes such as increasing size, pain, or signs of infection, but it does not take priority over assessing circulation and preventing limb-threatening complications.