A nurse is caring for a client who is at 30 weeks of gestation.
The nurse should plan to immunize the client with which of the following vaccines? (Select all that apply)

Choice A rationale: Calcium gluconate must be readily available whenever magnesium sulfate is administered because it serves as the antidote for magnesium toxicity. Magnesium sulfate depresses neuromuscular transmission and the central nervous system, which can lead to respiratory depression, hypotension, and cardiac arrest if serum levels become excessive. Having calcium gluconate on hand allows for immediate reversal of these life-threatening effects. This is a critical safety measure and therefore a required nursing action.

Choice B rationale: Respiratory status must be assessed at least every hour during magnesium sulfate therapy because respiratory depression is a primary sign of magnesium toxicity. Normal adult respiratory rate is 12 to 20 breaths per minute, and a rate below 12/min is concerning. Magnesium depresses the respiratory center in the medulla, and early recognition of hypoventilation is essential to prevent hypoxia and arrest. Thus, frequent respiratory monitoring is a priority nursing action.

Choice C rationale: Monitoring intake and output is essential because magnesium sulfate is excreted almost entirely by the kidneys. Oliguria, defined as urine output less than 30 mL/hr, increases the risk of magnesium accumulation and toxicity. Careful fluid balance assessment ensures adequate renal clearance and helps prevent complications such as pulmonary edema. Therefore, strict I&O monitoring is a critical nursing responsibility during magnesium sulfate therapy to ensure safe drug metabolism and excretion.

Choice D rationale: Intermittent fetal monitoring is not appropriate in this context. Magnesium sulfate administration and preterm labor with rupture of membranes require continuous fetal monitoring to detect early signs of distress. Intermittent monitoring risks missing decelerations or prolonged bradycardia. Continuous monitoring provides real-time assessment of fetal well-being and is the standard of care in high-risk obstetric situations. Therefore, intermittent monitoring is not a correct action and should not be selected.

Choice E rationale: Supine positioning is contraindicated in pregnancy, especially in the third trimester, because the gravid uterus compresses the inferior vena cava, leading to supine hypotensive syndrome. This decreases venous return, cardiac output, and uteroplacental perfusion, compromising both maternal and fetal oxygenation. The correct position is left lateral recumbent to optimize circulation. Therefore, placing the client supine is unsafe and not an appropriate nursing action in this scenario.

Choice A rationale

A nonreactive nonstress test (NST), defined by having fewer than two accelerations of at least 15 beats per minute (BPM) above baseline, lasting at least 15 seconds, within a 20-minute window, indicates potential fetal compromise or sleep state, leading to a maximum score of 0 on this component, thus not indicating well-being.

Choice B rationale

The biophysical profile (BPP) scores fetal movement with a maximum of 2 points for three or more discrete body or limb movements within a 30-minute period. The finding of four limb movements clearly meets this criterion and earns the full 2 points, reflecting an intact central nervous system and adequate fetal oxygenation, which is a sign of fetal well-being.

Choice C rationale

The BPP criterion for fetal breathing movements requires at least one episode of sustained movements for 30 seconds within the 30-minute observation period to score 2 points. The finding of 20 seconds is insufficient to meet this 30-second threshold, resulting in a score of 0 points for this component and thus not indicating full well-being.

Choice D rationale

The amniotic fluid index (AFI) measures the sum of the deepest vertical pockets of amniotic fluid in the four quadrants of the uterus. An AFI of 1 cm is significantly below the normal range of 5 cm to 25 cm, indicating oligohydramnios (low fluid). This finding scores 0 points on the BPP and suggests potential chronic fetal compromise or renal issues.