A nurse is assisting with the care of a client who is using paced breathing during the first stage of labor.
The client says she feels lightheaded and her fingers are tingling.
Which of the following actions should the nurse take?

Choice A rationale:

Administering the measles, mumps, rubella (MMR) vaccine two weeks before attempting pregnancy again is not the correct timing. It is important to provide the MMR vaccine postpartum before the client is discharged from the hospital after giving birth. This timing is appropriate to protect the woman from rubella and to avoid vaccinating during pregnancy.

Choice B rationale:

The correct timing for the MMR vaccine is prior to discharge from the hospital after giving birth. This approach ensures that the woman is protected against rubella before leaving the hospital and potentially becoming pregnant again. It is crucial to avoid vaccinating during pregnancy because the MMR vaccine contains live attenuated viruses.

Choice C rationale:

Administering the MMR vaccine prior to giving birth is not the recommended timing. Vaccination should be done postpartum to avoid any potential risks to the developing fetus.

Choice D rationale:

Administering the MMR vaccine when the client does not desire future pregnancies is not the most appropriate option. The vaccine should be given postpartum to protect the woman and any future pregnancies from rubella. It is important to provide vaccination recommendations based on evidence-based guidelines and the client's specific situation.

Choice A rationale:

Decreased energy Rationale: Decreased energy is a common symptom during pregnancy due to hormonal changes and increased metabolic demands. While it can be uncomfortable for the client, it is not typically a cause for immediate concern. It is essential to educate the client about the normal changes in energy levels during pregnancy, and that this symptom alone does not warrant calling the provider.

Choice B rationale:

Urinary frequency Rationale: Urinary frequency is a common early pregnancy symptom, primarily attributed to hormonal changes and the growing uterus pressing on the bladder. While it is a normal symptom, it can also be associated with urinary tract infections or other urinary issues. The client should call her provider if she experiences urinary frequency to rule out any potential problems.

Choice C rationale:

Mood swings Rationale: Mood swings are a common occurrence during pregnancy due to hormonal fluctuations. While they can be distressing for the client, they are typically not a sign of an immediate issue that requires contacting the provider. The nurse should educate the client about mood swings being a part of the normal pregnancy experience.

Choice D rationale:

Facial edema Rationale: Facial edema, or swelling of the face, can occur during pregnancy due to fluid retention. However, this symptom is not typically a cause for immediate concern. The nurse should educate the client about normal pregnancy-related changes, including mild edema. Severe facial edema might be a sign of preeclampsia, a condition characterized by high blood pressure and organ damage, but it is generally not a common early sign in pregnancy.