A nurse is caring for an infant who has coarctation of the aorta.
Which of the following should the nurse identify as an expected finding?

Advance directives are legal documents that allow a person to express their wishes for medical care in case they become incapacitated or unable to communicate. They do not require a lawyer or a notary to be valid, as long as they follow the state laws and are signed by the person and two witnesses.

Choice A is wrong because it implies that legal representation is necessary for advance directives, which is not true.

A social worker can help the client with other resources or support, but not with finding a lawyer for this purpose.

Choice C is wrong because it suggests that advance directives can be verbal, which is not true. Advance directives must be written and signed to be legally binding.

Verbal agreements may not be honored or remembered by the provider or the family.

Choice D is wrong because it implies that advance directives need legal review, which is not true. Advance directives are personal decisions that do not need to be approved by a lawyer or a court.

Legal review may be helpful in some cases, but it is not mandatory or essential.

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.