Exhibits

The nurse is assessing the client 15 minutes later. How should the nurse interpret the following findings?

Choice A rationale

The Diphtheria-tetanus-acellular pertussis (Tdap) vaccine is recommended during each pregnancy, ideally between 27 and 36 weeks of gestation. This timing is crucial because it allows for the maternal production and optimal transplacental transfer of pertussis antibodies to the fetus. These antibodies provide crucial passive immunity to the newborn against pertussis (whooping cough), which is a severe and potentially fatal disease in infants before they can be directly immunized.

Choice B rationale

The Human papillomavirus (HPV) vaccine is not recommended during pregnancy because there is limited safety data regarding its use in pregnant women. While it is not known to cause adverse fetal effects, it is a recombinant vaccine and, as a precautionary measure, it should be delayed until the postpartum period. Routine HPV vaccination is typically administered to adolescents and young adults up to age 26.

Choice C rationale

The Varicella vaccine is a live attenuated virus vaccine and is contraindicated in pregnancy due to the theoretical risk of transmission of the live virus to the fetus, which could potentially cause congenital varicella syndrome. Women who are non-immune to varicella should receive this vaccine postpartum, before being discharged from the hospital, to protect future pregnancies.

Choice D rationale

The Measles, mumps, and rubella (MMR) vaccine is a live attenuated virus vaccine and is contraindicated in pregnancy due to the theoretical risk of fetal infection and subsequent congenital abnormalities, particularly from the rubella component. Women who are not immune to rubella should be vaccinated postpartum and advised to avoid conception for about one month following vaccination.

Choice E rationale

The inactivated influenza (flu shot) vaccine is recommended for all women who are pregnant during the flu season, regardless of their stage of gestation, including at 30 weeks. This is a killed virus vaccine and is considered safe in pregnancy. It protects the mother from severe influenza illness and also provides the newborn with passive immunity in the initial months of life.

Choice A rationale

Misoprostol is a prostaglandin analog used to prevent or treat postpartum hemorrhage by inducing uterine contractions, but it is not the primary intervention for preeclampsia without severe features, which focuses on blood pressure control and seizure prophylaxis.

Choice B rationale

Administering an IV bolus of lactated Ringer's is generally contraindicated in preeclampsia because it can increase the risk of pulmonary edema due to generalized fluid retention and increased capillary permeability characteristic of the disorder. Fluid management should be conservative.

Choice C rationale

Clonus, which is the presence of rhythmic, involuntary muscle contractions, is a sign of hyperreflexia and central nervous system irritability. It indicates worsening preeclampsia and the potential progression to eclampsia (seizures), necessitating close neurological assessment for timely intervention.

Choice D rationale

Restricting daily oral fluid intake can lead to dehydration and is not a standard or necessary practice for preeclampsia management without severe features, unless there is evidence of pulmonary edema or acute kidney injury. The focus is on careful fluid balance, not routine restriction.