A single pregnant adolescent has decided to continue the pregnancy and keep the baby.
Which intervention would the nurse use?
Explore other problems that the client may be experiencing.
Praise and give approval for making a wise decision.
Making an appointment for the client to visit a prenatal clinic.
Provide information about resources and assistance.
The Correct Answer is D
Choice A rationale
While exploring other client problems is a component of holistic care, it is not the most immediate and direct priority after a major decision like continuing pregnancy. The primary focus should shift to practical support and preparation for the forthcoming maternal role and necessary resources, ensuring safety and continuity of care.
Choice B rationale
Giving explicit approval is non-therapeutic and can interfere with the client's autonomy and decision-making process. The nurse's role is to provide nonjudgmental, supportive care and information, respecting the client's choice without imposing personal values or moral judgments on the situation.
Choice C rationale
Making an appointment is a practical step, but providing information about resources empowers the adolescent to navigate the complex healthcare system and social support networks independently, which is a broader and more enabling intervention for long-term self-care and success.
Choice D rationale
Providing information about resources and assistance, such as WIC, Medicaid, and parenting classes, directly addresses the practical and socio-economic challenges inherent in an adolescent pregnancy. This is essential for promoting positive maternal-fetal outcomes and self-efficacy in the client's chosen path.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Monitoring blood glucose every six hours is insufficient for a high-risk neonate. Due to the sudden cessation of high maternal glucose supply and persistently high fetal insulin levels, the infant is at risk for rapid drops in glucose, requiring monitoring as frequently as every 1 to 3 hours initially.
Choice B rationale
High maternal glucose levels lead to fetal hyperglycemia and subsequent pancreatic beta-cell hyperplasia and hyperinsulinemia in the infant. After birth, the maternal glucose supply is cut off, but the hyperinsulinemia persists, rapidly driving the infant's blood glucose down, making hypoglycemia the most immediate, life-threatening risk.
Choice C rationale
While parent education is an important long-term goal, it is not the priority over immediate physiological assessment and intervention for a potentially life-threatening condition like hypoglycemia. Explanations should follow stabilization of the infant's vital parameters.
Choice D rationale
Estimating caloric needs is part of the overall care plan, but the priority is to identify and prevent the acute metabolic complication of hypoglycemia. Glucose monitoring and appropriate feeding or intravenous dextrose are the immediate interventions for prevention and treatment.
Correct Answer is ["C","D","E","F"]
Explanation
Choice A rationale
Rupture of membranes for 26 hours constitutes prolonged rupture, raising the risk of intrauterine infection (chorioamnionitis). An active infection or high suspicion is a strong contraindication to a trial of labor after cesarean (TOLAC) due to the physiological stress on the mother and fetus, increasing the risk of uterine rupture and septic complications, thus requiring delivery.
Choice B rationale
A current separation of the symphysis pubis causes pelvic instability and severe pain. The biomechanical stress of labor and pushing could seriously worsen this condition, leading to severe chronic pain or functional disability for the mother. This significant maternal orthopedic risk factor contraindicates a trial of labor after cesarean (TOLAC) and favors a planned repeat cesarean section.
Choice C rationale
A prior cesarean for placenta previa, where the placenta covered the cervix, is considered a non-recurrent indication in a subsequent pregnancy, provided the current placenta is normally implanted. The previous surgery was for a transient placental issue, not a permanent structural maternal or fetal condition, making the client a candidate for a trial of labor after cesarean (TOLAC).
Choice D rationale
A previous cesarean due to breech presentation, a fetal positioning issue, is generally a non-recurrent indication if the current fetus is cephalic (head-down). This transient fetal factor does not inherently compromise the safety of the maternal pelvis or the integrity of the prior uterine scar, thus favoring an attempt at a trial of labor after cesarean (TOLAC).
Choice E rationale
Group B streptococcal (GBS) colonization is a routine finding requiring intrapartum antibiotic prophylaxis (IAP) to prevent neonatal GBS disease. GBS positivity itself is not a contraindication to a trial of labor after cesarean (TOLAC) because the infection risk is managed with standard antibiotic protocols that can be administered during labor.
Choice F rationale
The gynecoid pelvis is anatomically the most suitable shape for vaginal birth, characterized by a rounded inlet and favorable dimensions that facilitate the cardinal movements of labor. This optimal maternal anatomy significantly improves the probability of a successful trial of labor after cesarean (TOLAC) and supports the attempt.
Choice G rationale
A traditional (classical or vertical) cesarean incision extends through the thick contractile upper segment of the uterus, which heals less robustly than a low transverse incision. This incision type carries a significantly higher risk of uterine rupture during labor (approximately 4-9.
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