A nurse is caring for a client who is experiencing severe pain during active labor.
Which of the following medications should the nurse plan to administer and document in the client's medical record?

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.

The nurse should further evaluate respiratory characteristics and muscle tone to determine if the newborn is experiencing a complication.

Rationale for correct answers
Respiratory characteristics are critical to assess because irregular and shallow breathing in a newborn can indicate neurological or respiratory dysfunction. Normal neonatal respiratory rate ranges from 30 to 60 breaths per minute with regular pattern; deviations may signal distress or central nervous system issues. Muscle tone evaluation is essential since increased tone with tremors suggests possible neurologic irritability or withdrawal. Normal newborn muscle tone should be moderate, neither hypotonic nor hypertonic, with symmetrical movement. These signs correlate with the high-pitched cry, tremors, and exaggerated reflexes noted, which may indicate neurological complications such as withdrawal syndrome or hypoxic-ischemic encephalopathy.

Rationale for incorrect answers
Heart rate (A) is important but was not reported abnormal; normal neonatal heart rate ranges from 120 to 160 beats per minute and the absence of murmurs suggests no cardiac compromise. Temperature (C) is less urgent as mucous membranes are moist and skin warm and dry, indicating stable thermoregulation; normal newborn temperature is 36.5–37.5°C. Feeding patterns (D) appear adequate with no difficulty reported, making this less immediately concerning.

Rationale for incorrect answers
Moro reflex (A) and Babinski reflex (B) are both present and exaggerated, which may be reactive but less specific for immediate concern than muscle tone abnormalities. Skin color (D) is normal without cyanosis or jaundice, reducing the likelihood of hypoxia or hemolytic issues.

Take home points

• Respiratory pattern irregularities in newborns may indicate neurological or respiratory dysfunction.
• Abnormal muscle tone and tremors are key signs of potential neurological complications.
• Normal heart rate, temperature, feeding, and skin color reduce likelihood of cardiac or systemic illness.
• Reflex exaggeration alone is less specific than muscle tone and respiratory changes for early complication detection.