A nurse is reinforcing teaching about immunizations to a client who is pregnant. Which of the following immunizations should the nurse identity as contraindicated during pregnancy?

A. Witnessing the death of their parents and sibling: Experiencing such severe trauma places the client at high risk for post-traumatic stress disorder (PTSD) and complicated grief. Immediate follow-up is necessary to assess emotional safety and provide appropriate mental health interventions.

B. Attends school regularly: Regular school attendance is a positive sign of functioning and does not require immediate follow-up. It indicates that the client maintains some level of daily routine and social engagement.

C. Client experiences nightmares: Nightmares following trauma can indicate PTSD or acute stress reaction. These symptoms warrant prompt assessment and intervention to prevent worsening sleep disturbances, anxiety, or functional impairment.

D. Blood pressure 122/80 mm Hg: This is within normal limits for a 16-year-old and does not require immediate follow-up. It is not indicative of acute physical risk.

E. Heart rate 99/min: While slightly elevated, this heart rate is within a mild range of normal for adolescents under stress and does not require immediate follow-up unless accompanied by other acute symptoms.

F. Startles easily during thunderstorms: A mild startle response, especially with a prior fear of storms, is not an urgent concern. While it may relate to trauma, it is not immediately dangerous or requiring urgent follow-up.

G. Friend reporting client is not themselves: Changes in behavior observed by peers can indicate worsening mental health or risk of self-harm. Immediate follow-up is important to evaluate mood, coping, and safety.

H. Smoking marijuana to clear their mind: Self-medicating with substances is a significant safety concern, particularly in adolescents coping with trauma. Immediate follow-up is required to assess for substance use disorder and potential harm to mental and physical health.

A. The nurse opened the package of gauze toward their body: Opening a sterile package toward the body increases the risk of contaminating the contents. Sterile materials should always be opened away from the nurse to maintain sterility.

B. The nurse kept their hands above the waist during the dressing change: Keeping hands above the waist helps maintain the integrity of the sterile field. Anything below waist level is considered contaminated, so this action demonstrates proper sterile technique.

C. The nurse handled the sterile gauze with clean gloves on: Sterile gloves, not clean gloves, are required to handle sterile materials. Using clean gloves could introduce microorganisms and compromise sterility.

D. The nurse placed a bottle of saline on the sterile field: Only items that are sterile should be placed on the sterile field. Placing a non-sterile bottle of saline directly on the field can cause contamination.