A nurse is caring for a client who is scheduled for a bronchoscopy. The client states, "I no longer wish to have this procedure." Which of the following responses should the nurse make?

Rationale:

A. Withhold the medication until the provider signs the prescription: Waiting for the provider's signature before administering a telephone order may delay critical care. Verbal or telephone orders can be acted upon immediately if clearly understood, documented, and later signed by the provider within the facility’s required timeframe.

B. Record the date and time of the telephone prescription: Accurate documentation includes noting the date and time the telephone order was received. This ensures clarity, legal compliance, and proper sequencing of medical events in the client's record.

C. Request that the provider confirm the read-back of the prescription: A read-back process reduces the risk of medication errors by confirming that the nurse correctly heard and understood the provider’s order. It is a Joint Commission-recommended safety practice.

D. Ask the provider to spell out the name of the medication: Asking the provider to spell out high-risk or sound-alike medications helps avoid transcription errors. This step is especially important when communication clarity is compromised over the phone.

E. Instruct another nurse to record the prescription in the medical record: The nurse receiving the order is responsible for documenting it. Delegating this task to another nurse increases the chance of miscommunication and errors, and violates proper protocol.

Rationale:

A. Measles, mumps, and rubella (MMR): MMR is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of fetal harm. It should be given at least one month prior to conception or postpartum if immunity is needed.

B. Varicella (VAR): Like MMR, the varicella vaccine is live and should not be administered during pregnancy. Pregnant individuals without evidence of immunity should receive it postpartum to protect against future infections.

C. Tetanus diphtheria and pertussis (Tdap): Tdap is recommended during each pregnancy but typically between 27 and 36 weeks of gestation to maximize passive antibody transfer to the fetus. At 16 weeks, it would not yet be indicated.

D. Inactivated influenza (IV): The inactivated flu vaccine is recommended for all pregnant clients during flu season, regardless of the trimester. It protects both the pregnant individual and the fetus from complications related to influenza infection.