A nurse is assessing a 13-year-old female client during a school physical.
Which physical changes associated with female adolescence should the nurse expect? Select all that apply.

Choice A rationale

Identifying the timing and frequency of physical contact provides data on the chronicity of the events but does not immediately clarify the specific intent or the exact physical nature of the interaction. While establishing a pattern is useful for long-term documentation in forensic nursing, it is secondary to understanding the immediate context of the physical contact to determine if the actions meet the legal and clinical definitions of non-accidental trauma or child abuse.

Choice B rationale

Assessing the nature and circumstances of the physical contact is the priority because it allows the nurse to distinguish between culturally specific disciplinary practices and actual physical abuse. The nurse must determine if the hitting results in injury, such as bruising or lacerations, and the specific context in which it occurs. This detailed information is essential for mandated reporting and ensures that the safety of the child is evaluated based on the severity and intent of the uncle.

Choice C rationale

The age of the uncle is a demographic detail that may be relevant for a police report or a social services investigation, but it does not provide insight into the safety of the child or the nature of the physical interaction. Knowing the perpetrator's age does not help the nurse assess the child's physical condition or the risk of further injury, making it a lower priority than the details of the physical contact itself.

Choice D rationale

Determining the child's level of familiarity with the uncle helps establish the relationship dynamics within the household or family structure. However, the degree of acquaintance does not change the clinical or legal threshold for reporting suspected abuse. Even if the child knows the uncle well, the nurse's primary responsibility is to investigate the physical act described and determine if the child is in immediate danger of further physical harm or neglect.

Choice A rationale

Choice A rationale:

Human immunodeficiency virus is a high-risk condition because it can be transmitted from the mother to the fetus during pregnancy, labor, or breastfeeding. Without intervention, the risk of vertical transmission is significant. However, with antiretroviral therapy and proper management, the transmission rate can be reduced to less than 1 percent. It requires intensive monitoring of viral loads and CD4 counts throughout the pregnancy to ensure optimal outcomes.

Choice B rationale

A previous history of a normal delivery at 40 weeks gestation is considered a low-risk factor. It suggests that the mother's reproductive system is capable of carrying a fetus to full term and delivering without major complications. Past obstetric performance is a strong predictor of future outcomes. This history typically places the mother in a routine care category rather than a high-risk category, provided no new medical conditions have developed.

Choice C rationale

Diabetes, whether pregestational or gestational, is a high-risk condition that affects maternal and fetal health. Poorly controlled blood glucose levels increase the risk of congenital anomalies, macrosomia, and neonatal hypoglycemia. Normal fasting glucose should be less than 95 mg/dL. Management involves strict glycemic control through diet, exercise, or insulin. These patients require frequent fetal surveillance, such as non-stress tests and ultrasounds, to monitor for complications like polyhydramnios.

Choice D rationale

Hypertension is a major high-risk factor associated with preeclampsia, placental abruption, and intrauterine growth restriction. Chronic hypertension is defined as blood pressure ≥ 140/90 mmHg before pregnancy or before 20 weeks gestation. It can lead to decreased placental perfusion, resulting in fetal hypoxia and low birth weight. Monitoring blood pressure, protein in the urine, and signs of end-organ damage is essential for the safety of both the mother and child.