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. Respiratory data: The client’s respirations are even and nonlabored, with clear lung sounds and an oxygen saturation of 94% on room air. Although the respiratory rate is mildly elevated, there are no signs of pulmonary edema or respiratory compromise requiring immediate follow-up.

B. Lower extremity data: The presence of 1+ dependent edema bilaterally can be a normal finding in pregnancy due to increased fluid volume and venous stasis. In isolation, this level of edema does not indicate a critical concern requiring urgent follow-up.

C. Nausea: Nausea and vomiting in the third trimester, especially when accompanied by headache and right epigastric pain, are concerning for severe preeclampsia. These symptoms suggest hepatic involvement and warrant prompt follow-up and evaluation.

D. Deep tendon reflex: Hyperreflexia with 3+ deep tendon reflexes indicates increased neuromuscular irritability. This finding is associated with preeclampsia and increases the risk for seizure activity, making it a priority for follow-up.

E. Blood pressure: A blood pressure of 156/96 mm Hg meets the criteria for hypertension in pregnancy. Persistent elevations place the client at risk for preeclampsia and related complications and require immediate provider notification.

F. Fundal height: At 30 weeks’ gestation, an expected fundal height is approximately 30 cm. A measurement of 26 cm suggests possible intrauterine growth restriction, which may be related to placental insufficiency and requires further assessment.

G. Weight data: A weight gain of 0.68 kg (1.5 lb) in one week may indicate abnormal fluid retention. Rapid weight gain in pregnancy is a concerning sign of worsening preeclampsia and should be followed up promptly.

A. Observe the client during and after meals: Monitoring the client for bingeing or purging behaviors is the priority intervention because it addresses immediate safety and physical health risks, such as electrolyte imbalances. Direct observation prevents harmful behaviors and allows timely intervention.

B. Refer the client to a support group for clients who have eating disorders: Referral is important for long-term psychosocial support, but it does not address immediate risk or safety concerns during meals.

C. Instruct the client about effective coping strategies: Teaching coping strategies is beneficial for long-term management, but ensuring safety during meals takes precedence in the nursing process.

D. Suggest that the client assist with meal planning: Involving the client in meal planning promotes autonomy and engagement in treatment, but it is not the first action when immediate monitoring is required to prevent harmful behaviors.