A nurse is caring for a 28-year-old female client who is at 12 weeks of gestation and has been admitted to the emergency department with excessive vomiting for the past 48 hours. The client has lost 2.3 kg (5 lb) over 2 days.

Exhibits

The nurse is assessing the client 24 hours later. How should the nurse interpret the findings 24 hours later? For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening.

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
Instructing the client to avoid urinary elimination until after administration is not necessary. The administration of dinoprostone does not interfere with the client’s ability to urinate.
Therefore, this action is not required.
Choice B rationale
Placing the client in a semi-Fowler’s position for 1 hr after administration is not a necessary action. While positioning can be important in certain medical procedures, there is no specific requirement for a semi-Fowler’s position in the administration of dinoprostone.
Choice C rationale
Verifying that informed consent is obtained prior to administration is a crucial step in any medical procedure, including the administration of dinoprostone. Informed consent ensures that the client is aware of the procedure, its purpose, and any potential risks or benefits. It is a legal and ethical requirement.
Choice D rationale
Allowing the medication to reach room temperature prior to administration is not a necessary action. There is no specific requirement for dinoprostone to be at room temperature before administration.