A nurse is caring for an adolescent who is scheduled for insertion of an intrauterine device. Which of the following actions should the nurse take?

Encourage the adolescent to wait to ask questions about the device until after its insertion.

Call the adolescent's guardian to obtain verbal consent prior to the procedure.

Reschedule the procedure until the client's guardian provides written consent.

Witness the adolescent's signature on the consent form.

Answer and Explanation

The Correct Answer is D

A. "Encourage the adolescent to wait to ask questions about the device until after its insertion." The adolescent should be encouraged to ask questions before the procedure to ensure informed consent and understanding.

B. "Call the adolescent's guardian to obtain verbal consent prior to the procedure." In many areas, adolescents can provide consent for reproductive health services, including contraception, without parental consent.

C. "Reschedule the procedure until the client's guardian provides written consent." Most states and healthcare policies allow minors to consent to birth control procedures without requiring parental involvement.

D. "Witness the adolescent's signature on the consent form." The nurse should witness and document the adolescent’s informed consent, as they have the right to make decisions regarding their reproductive health.

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Correct Answer is B

Explanation

A. Elevated temperature. An elevated temperature is a common symptom of infection, including bacterial pneumonia, but it is not a direct risk factor for aspiration. The concern for aspiration is more related to a child's ability to protect their airway.

B. Neurological deficit. A neurological deficit, such as a decreased level of consciousness or impaired swallowing reflexes, increases the risk of aspiration. A child with neurological impairment may have difficulty swallowing or protecting their airway, making them more prone to inhaling food, fluids, or other substances into the lungs, leading to aspiration pneumonia.

C. Inspiratory wheezing. Inspiratory wheezing is more likely to be associated with conditions like asthma or airway obstruction, not specifically with aspiration. It does not directly indicate a risk for aspiration.

D. Rapid respirations. Rapid respirations can be a sign of respiratory distress, common in pneumonia, but they do not directly indicate a risk for aspiration. The risk for aspiration is more closely linked to issues with swallowing and airway protection, not just the rate of respiration.

A. Place the infant in a supine position. B. Allow the infant to sleep through night feedings. C. Minimize the infant's environmental stimuli. D. Bathe the infant every day.

Correct Answer is C

Explanation

A. "Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.

B. "Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.

C. "Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.

D. "Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.

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A nurse is caring for an adolescent who is scheduled for insertion of an intrauterine device. Which of the following actions should the nurse take?

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