When planning care for a laboring client, the practical nurse (PN) identifies the need to withhold solid foods while the client is in labor.
Which is the most important reason for this nursing intervention?

Choice A rationale

The Varicella vaccine (chickenpox) is typically recommended for administration to children at 12 to 15 months of age, not at 2 months. Administering it earlier would not provide optimal immune response due to the presence of maternal antibodies, which can interfere with vaccine efficacy, rendering the immunization less effective at stimulating active immunity in the infant.

Choice B rationale

Hepatitis A vaccine is generally recommended for children starting at 12 months of age, with a second dose 6 to 18 months after the first. It is not typically administered to 2-month-old infants. The immunization schedule is designed to optimize the infant's immune system response to the vaccine at specific developmental stages, ensuring effective long-term protection.

Choice C rationale

The Hepatitis B vaccine is routinely administered at birth, followed by doses at 1 to 2 months and 6 to 18 months of age. Therefore, a 2-month-old infant is due for their second dose of the Hepatitis B vaccine as part of the standard childhood immunization schedule. This multi-dose regimen ensures robust and sustained immunity against the hepatitis B virus.

Choice D rationale

The Measles, Mumps, Rubella (MMR) vaccine #1 is typically administered to children at 12 to 15 months of age. Administering it at 2 months would not be appropriate. The timing is crucial for maximizing the immune response and minimizing potential interference from maternal antibodies, which are still present in significant levels at 2 months and can reduce vaccine effectiveness. .

Choice A rationale

Monitoring serum electrolytes is the top priority for an infant with congenital adrenal hyperplasia (CAH). This condition involves an enzymatic defect that impairs cortisol and aldosterone synthesis, leading to salt wasting due to insufficient aldosterone. This can cause life-threatening hyponatremia and hyperkalemia, requiring urgent intervention. Normal ranges are typically sodium 135-145 mEq/L and potassium 3.5-5.0 mEq/L.

Choice B rationale

Checking for hypothermia is important for any neonate or infant, as they have immature thermoregulation. While a general nursing intervention, it is not the most specific or life-threatening concern directly related to the pathophysiology of congenital adrenal hyperplasia, which primarily involves electrolyte imbalances.

Choice C rationale

Assessing for urinary tract infection is a relevant general health assessment, especially in infants with ambiguous genitalia, due to potential anatomical variations. However, while important for overall health, it does not address the immediate, life-threatening metabolic derangements associated with congenital adrenal hyperplasia.

Choice D rationale

Recording daily weights is crucial for assessing fluid balance in infants, particularly those at risk for dehydration or fluid retention. While important for monitoring overall health and fluid status, it is secondary to the critical need to monitor and correct acute electrolyte imbalances that can rapidly become life-threatening in CAH.