A nurse is caring for a client who is at 35 weeks of gestation and is receiving magnesium sulfate for treatment of preeclampsia.
Which of the following findings indicates that the medication is having the desired effect?

Choice A rationale

Diphtheria-acellular pertussis (Tdap) vaccine is recommended for pregnant clients during the third trimester, specifically between 27 and 36 weeks of gestation. This timing optimizes the transfer of maternal antibodies to the fetus, providing passive immunity against pertussis (whooping cough) in the newborn during their vulnerable early months, before they are old enough to receive their own vaccinations.

Choice B rationale

Inactivated influenza vaccine is highly recommended for pregnant clients during any trimester of pregnancy. Pregnancy alters the immune system, making pregnant individuals more susceptible to severe complications from influenza. Vaccination protects both the mother and, through passive antibody transfer, the newborn from influenza infection.

Choice C rationale

Varicella vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection. While the actual risk is very low, it is generally deferred until the postpartum period. Women of childbearing age should be screened for immunity and vaccinated if non-immune prior to conception or postpartum.

Choice D rationale

Measles, mumps, and rubella (MMR) vaccine is a live attenuated vaccine and is contraindicated during pregnancy due to the theoretical risk of fetal infection, particularly with rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, causing severe birth defects. Vaccination should occur before conception or postpartum.

Choice E rationale

Human papillomavirus (HPV) vaccine is not routinely recommended during pregnancy. While current data do not suggest harm, the vaccine has not been extensively studied in pregnant individuals. Vaccination should be completed before pregnancy or deferred until the postpartum period.

Choice A rationale

Bladder distention upon palpation indicates urinary retention, not effective voiding. When the bladder remains distended, it signifies incomplete emptying, which can lead to urinary stasis and increased risk of urinary tract infections. Effective voiding requires coordinated detrusor muscle contraction and urethral sphincter relaxation, which is absent with distention.

Choice B rationale

A uterine fundus 2 cm above the umbilicus, especially in the postpartum period, suggests uterine atony and possible bladder distention. A full bladder can displace the uterus upward and to the side, preventing effective uterine contraction and involution, which is crucial for preventing postpartum hemorrhage. Normal fundal height should decrease daily.

Choice C rationale

Not feeling the urge to urinate could indicate nerve damage, overdistention with sensory nerve suppression, or a very low urine output. Normal bladder sensation is crucial for effective voiding. The absence of the urge may lead to prolonged bladder distention, increasing the risk of infection and bladder dysfunction, which hinders efficient emptying.

Choice D rationale

Urinating 30 mL/hr, while seemingly low, is a continuous output and suggests the client is able to empty their bladder, albeit slowly. Postpartum diuresis typically begins within 12 hours, with urine output of 100 to 250 mL/hr common. However, any consistent output, rather than retention, indicates some voiding effectiveness.