A nurse is performing CPR on a 6-month-old infant.
Which technique for chest compressions should the nurse utilize?

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

The formation of ovaries is not a physical change expected during adolescence; rather, it is a developmental process that occurs during fetal gestation. By the time a female reaches puberty, the ovaries are already present and contain a lifetime supply of primordial follicles. Adolescence involves the maturation and activation of these organs under the influence of gonadotropins, not their initial formation. Therefore, this is not a visible adolescent physical change.

Choice B rationale

Menarche, the onset of the first menstrual period, is a hallmark of female adolescent development and typically occurs about two years after the initial appearance of breast buds. It signifies that the hypothalamic-pituitary-gonadal axis has matured enough to induce ovulation and uterine lining shedding. This biological milestone is a key indicator of reproductive maturity. It usually occurs between the ages of 10 and 15, with an average around 12 years.

Choice C rationale

Breast development, or thelarche, is usually the first visible sign of puberty in females. It is driven by increasing levels of estrogen produced by the maturing ovaries. This process involves the enlargement of the areola and the growth of glandular tissue behind the nipple. Thelarche is staged using the Tanner scale to track progression. It is a predictable and expected physical change that occurs early in the adolescent transition.

Choice D rationale

Pubic hair growth, known as adrenarche or pubarche, is a standard physical change in adolescence resulting from increased androgen production from the adrenal glands and ovaries. It typically follows the onset of breast development but can sometimes occur simultaneously. The hair progresses from sparse and downy to thick, curly, and dark. This is an expected finding during a physical exam for a 13-year-old female as she moves through developmental stages.

Choice E rationale

During female adolescence, there is typically an increase in adipose tissue rather than a decrease. Estrogen promotes the deposition of fat in specific areas such as the hips, thighs, and breasts to create the characteristic female body shape. This physiological change is necessary for maintaining the energy stores required for menstruation and future reproductive health. A decrease in adipose tissue would be an abnormal finding unless the client is extremely athletic.