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

Bladder distention upon palpation indicates urinary retention, meaning the client is unable to void effectively or empty the bladder completely. In the postpartum period, a full bladder can inhibit uterine contraction and increase the risk of postpartum hemorrhage because a distended bladder displaces the uterus, preventing it from clamping down appropriately. The normal range for post-void residual volume is typically less than 100 mL.

Choice B rationale

Not feeling the urge to urinate may be due to decreased bladder sensation following labor and delivery or effects of regional anesthesia, which can lead to urinary retention. Effective voiding is characterized by the ability to sense the urge to void, initiate urination, and empty the bladder, typically passing at least 150 mL per void after catheter removal.

Choice C rationale

Lateral displacement of the uterus is a common sign of a distended bladder. A full bladder pushes the uterus out of its normal midline position, impairing its ability to contract effectively, which increases the risk for uterine atony and subsequent postpartum hemorrhage. The fundus should remain firm and in the midline position after effective voiding.

Choice D rationale

The firming of the fundus with massage indicates that the uterus is contracting, which is essential for preventing postpartum hemorrhage by compressing the blood vessels at the placental site. Effective voiding allows the uterus to remain in its midline position, facilitating proper involution and contractility, which is reflected by a firm fundus.

Choice A rationale

Body tremors are a key indicator of central nervous system (CNS) hyperirritability, which is a major component of neonatal abstinence syndrome (NAS) following in utero exposure to opioids like heroin. The newborn's immature CNS struggles to adapt after the abrupt cessation of the drug, leading to uncoordinated, jerky movements, exaggerated reflexes, and generalized irritability.

Choice B rationale

Tachypneic respirations (respiratory rate greater than 60 breaths/min) are a common sign of NAS. This occurs due to the dysregulation of the autonomic nervous system and increased metabolic rate associated with the hyperirritable state. Other respiratory signs include flaring, retractions, and frequent yawning or sneezing, reflecting CNS overstimulation.

Choice C rationale

The hyperirritability of the CNS in NAS typically leads to increased and exaggerated reflexes (hyperreflexia), such as a hyperactive Moro reflex, not decreased reflexes. Decreased reflexes would suggest CNS depression, which is characteristic of acute opioid intoxication, not the withdrawal state of NAS.

Choice D rationale

Newborns experiencing NAS are characterized by CNS hyperstimulation, leading to excessive wakefulness, irritability, and an inability to be consoled, often referred to as hyperactivity or agitation. Extreme lethargy and hypoactivity are signs of CNS depression or severe illness, which is contrary to the expected presentation of NAS.

Choice E rationale

The hyper-responsiveness of the newborn's CNS in NAS causes a characteristic high-pitched, non-stop, inconsolable crying. This shrill, distressed cry is due to the sustained state of irritability and neurological overstimulation, representing a significant manifestation of withdrawal symptoms that is distressing to both the newborn and the caregivers.