A school nurse notices a sudden drop in grades and increased absenteeism in a previously high-achieving student.
When approached, the student avoids eye contact and has flat affect. What is the nurse's next best action?

Choice A rationale

Restraining a child with autism can exacerbate distress and lead to further agitation due to sensory overload and a feeling of loss of control. Physical restraint can activate the sympathetic nervous system, increasing heart rate and cortisol levels, which can traumatize the child and hinder therapeutic rapport, contravening principles of trauma-informed care.

Choice B rationale

Hand flapping and rocking are common self-stimulatory behaviors, or "stimming," in children with autism, serving to regulate sensory input and manage anxiety. Allowing these behaviors in a low-stimulus environment supports emotional regulation by reducing external stressors and promoting a sense of security, which is crucial for individuals with sensory processing differences.

Choice C rationale

Immediately redirecting or attempting to stop self-stimulatory behaviors can be counterproductive for a child with autism. These behaviors often serve a vital self-regulatory function; interrupting them without providing an alternative coping mechanism can increase anxiety, frustration, and escalate behavioral challenges, disrupting their internal equilibrium.

Choice D rationale

Engaging in verbal interaction to distract a child with autism during self-soothing can disrupt their regulatory process. Children with ASD often have difficulties with social communication and may find unexpected verbal input overwhelming, potentially increasing sensory overload and agitation, rather than providing effective distraction or comfort.

Choice A rationale

Report of insomnia is a common and often expected complaint during the third trimester of pregnancy due to physical discomforts such as frequent urination, fetal movement, and difficulty finding a comfortable position. While bothersome for the client, it is typically not indicative of a serious complication requiring immediate reporting to the provider in a routine prenatal visit.

Choice B rationale

Blood-tinged mucous vaginal discharge, or "bloody show," is a normal finding at 38 weeks of gestation. It indicates cervical changes such as effacement and dilation as the body prepares for labor. This physiological process results from the rupture of small capillaries in the cervix and is expected.

Choice C rationale

A blood pressure of 134/80 mm Hg, while slightly elevated from typical mid-pregnancy readings, is generally within acceptable limits for a 38-week gestation. A normal blood pressure range in pregnancy is typically less than 140/90 mm Hg. This reading alone does not indicate preeclampsia or other hypertensive disorders in the absence of other symptoms.

Choice D rationale

A weight gain of 2.2 kg (4.8 lbs) in one week at 38 weeks of gestation is concerning. Rapid weight gain during pregnancy, particularly in the third trimester, can be a sign of fluid retention and may indicate potential complications such as preeclampsia, a serious hypertensive disorder of pregnancy, and warrants prompt evaluation by the provider. .