A nurse is contributing to the plan of care for a client who is in the third trimester and reports difficulty sleeping. Which of the following statements should the nurse include?

Choice A reason:

Rotavirus The nurse does not need to administer the Rotavirus vaccine in this scenario. Rotavirus immunization is typically given to infants between 2 and 6 months of age to protect against severe diarrhea caused by the virus. Since the child in question is 4 years old and up to date on current immunizations, this vaccine is not necessary.

Choice B reason:

Hepatitis B (Hep B) Similarly, the Hepatitis B vaccine is usually given shortly after birth and completed in a series of doses over the first year of life. Since the 4-year-old child is up to date on immunizations, the Hep B vaccine would have already been administered as part of the routine childhood vaccination schedule.

Choice C reason:

Varicella The Varicella vaccine, also known as the chickenpox vaccine, is typically given between 12 and 15 months of age and then again at 4 to 6 years old. Since the child is 4 years old and up to date on immunizations, it is now time for them to receive the second dose of the Varicella vaccine, making Choice C the correct answer.

Choice D reason:

Haemophilus influenza (Hib) The Haemophilus influenza (Hib) vaccine is usually given to infants starting at 2 months of age and is administered in multiple doses. By 4 years old, the child would have completed the primary series of the Hib vaccine. Therefore, there is no need to administer this vaccine again.

Choice B reason: The nurse should ask the client if they have had thoughts about harming their infant. This is a crucial action because the client's statement suggests they may be experiencing feelings of inadequacy and self-doubt as a mother, which could potentially lead to more serious thoughts or actions. By directly asking about thoughts of harming the baby, the nurse can assess the client's mental and emotional state more thoroughly and determine if there is a risk of harm to the infant.

Choice A reason:

The nurse should advise the client that most new mothers experience these feelings. This response acknowledges the client's feelings of inadequacy and normalizes their experience, letting them know that it is common for new mothers to have doubts and insecurities. This validation can help the client feel less alone and more understood, promoting a therapeutic nurse-client relationship.

Choice C reason:

The nurse should explain to the client that they are experiencing the "baby blues.” This is a valid option because the client's statement indicates they may be experiencing mood swings, sadness, and emotional sensitivity, which are typical symptoms of the baby blues. Providing this information can help the client understand that these feelings are transient and often related to hormonal changes after childbirth.

Choice D reason:

Taking the client to the emergency department is not warranted based solely on the information provided. The client's statement does not indicate an immediate danger to themselves or their baby. However, if during the assessment (including choice B), the nurse identifies any signs of potential harm to the infant or the client, further action may be necessary, such as involving appropriate mental health professionals or support services.