A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia.
Which of the following responses by the nurse is appropriate?

Choice A rationale
The influenza vaccine is recommended for all pregnant women, but it is not the only vaccine that should be administered to a pregnant woman who has received no immunizations during childhood.
Choice B rationale
The Tetanus, Diphtheria, Pertussis (Tdap) vaccine is recommended for all pregnant women, regardless of their prior immunization status. This vaccine protects against three serious diseases caused by bacteria. The antibodies that the pregnant woman’s body makes in response to the vaccine are passed on to the baby through the placenta, providing the baby with short-term protection against these diseases until they can receive their own vaccines.
Choice C rationale
The Hepatitis B vaccine is not typically given during pregnancy unless the woman is at risk for Hepatitis B infection.
Choice D rationale
The Pneumococcal vaccine is not typically given during pregnancy unless the woman has certain health conditions that increase her risk for pneumococcal disease

Choice A rationale: A positive Coombs test indicates that the newborn has antibodies against his own red blood cells, which can lead to hemolytic disease of the newborn. This condition can cause severe anemia and jaundice, which can lead to complications such as kernicterus if not treated promptly.

Choice B rationale: The newborn’s glucose level is within the normal range (40 to 60 mg/dL), so this finding does not require immediate follow-up.

Choice C rationale: The yellow color of the sclera indicates jaundice, which can be a sign of hyperbilirubinemia. This condition can lead to complications such as kernicterus if bilirubin levels become too high.

Choice D rationale: The absence of meconium stool in a 36-hour-old newborn is unusual, as most newborns pass meconium within the first 24 to 48 hours after birth. This could indicate a problem such as meconium ileus or Hirschsprung disease, which would require further evaluation.

Choice E rationale: The head assessment finding of caput succedaneum is a common and typically harmless condition in newborns caused by pressure on the head during delivery. It does not require immediate follow-up.

Choice F rationale: The newborn’s heart rate is slightly elevated (normal range for a newborn is 120-160 beats per minute). This could be a response to factors such as fever, pain, or distress, and should be reported to the provider.

Choice G rationale: The newborn’s respiratory rate is also elevated (normal range for a newborn is 30-60 breaths per minute). This could be a sign of respiratory distress and should be reported to the provider.

Choice H rationale: Dry mucous membranes can be a sign of dehydration, which can occur if the newborn is not feeding well or is losing too much fluid, for example, through excessive sweating due to fever. This should be reported to the provider.