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 ["60"]
Explanation
Step 1 is: Convert the ordered rate from mU/min to mU/hr. 20 mU/min× 60 min/hr = 1200 mU/hr.
Step 2 is: Convert the available concentration from units/mL to mU/mL. 20 units = 20,000 mU (since 1 unit = 1000 mU). The concentration is 20,000 mU÷ 1000 mL = 20 mU/mL.
Step 3 is: Calculate the infusion rate in mL/hr. 1200 mU/hr÷ (20 mU/mL). 60 mL/hr. The oxytocin will infuse at 60 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
While the amount of blood loss is critical for determining the severity of the hemorrhage and the need for immediate treatment, it is not the priority assessment before administering methylergonovine. The amount of blood loss determines the need for the drug, but the blood pressure determines its safety before administration. Methylergonovine is a potent vasoconstrictor and must be used cautiously in clients with elevated blood pressure to prevent hypertensive crisis or stroke.
Choice B rationale
Methylergonovine is an ergot alkaloid that acts as a potent vasoconstrictor and uterine stimulant. Its primary side effect and contraindication are hypertension and preeclampsia. Because the drug dramatically increases systemic vascular resistance, it can cause a sudden, severe elevation in blood pressure. Therefore, checking the blood pressure is the priority assessment to ensure the client's pressure is within safe limits before administration, preventing potential complications like stroke.
Choice C rationale
Although a change in the level of consciousness (LOC) could indicate hypovolemic shock from severe blood loss or a hypertensive emergency, it is a secondary finding. The primary, direct, and modifiable risk associated with methylergonovine administration is its potential to cause acute, severe hypertension. Checking the client's baseline blood pressure (Choice B) is the specific, essential safety check before administering this vasoconstrictive medication.
Choice D rationale
The uterine tone or atony is the indication for the medication; the client is already diagnosed with uterine atony (flaccid uterus) causing the hemorrhage. The medication's purpose is to contract the uterus (increase tone). The priority before administration, however, is to assess the client for contraindications or serious adverse reaction risks. The potent vasoconstrictive effect on peripheral arteries makes blood pressure (Choice B) the most critical pre-administration safety assessment.
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