The nurse in the prenatal clinic is seeing a pregnant 16-year-old for the first time. What comment by the young woman is the most critical for the nurse to address first?
1. "My favorite lunch is burger and fries.".
2. "I've been dating my new boyfriend for 2 weeks.".
3. "On weekends, we go out and drink a few beers.".
4. "I dropped out of school about 3 months ago.".
3
Rationale 1: Even though a burger and fries are not the healthiest lunch, it is not the most critical statement for the nurse to address.
Rationale 2: Although this comment is cause for concern, as it suggests that the patient has many partners, it is not the most important issue.
Rationale 3: The nurse responds to this statement because of the danger of fetal alcohol syndrome.
Rationale 4: It is important for the patient to finish her education, but her education is not the nurse's first priority to address.
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