Examkin

Question

Difficulty: MediumHealth Promotion and Disease Prevention

A practical nurse (PN) is reviewing the health records of four clients scheduled for immunizations at a community health clinic. The PN should withhold the vaccine and notify the healthcare provider for which client?

  1. A 28-year-old client who is 14 weeks pregnant and prescribed the measles, mumps, and rubella (MMR) vaccine.Answer
  2. B
    A 65-year-old client with type 2 diabetes mellitus who is prescribed the annual inactivated influenza vaccine.
  3. C
    A 45-year-old client with a mild upper respiratory infection without fever who is prescribed the tetanus, diphtheria, and pertussis (Tdap) vaccine.
  4. D
    A 15-month-old toddler with a history of mild injection site redness from a previous dose who is prescribed the pneumococcal conjugate vaccine.

Answer

The 28-year-old pregnant client prescribed the measles, mumps, and rubella (MMR) vaccine.
The measles, mumps, and rubella (MMR) vaccine is a live attenuated virus vaccine. Live vaccines are strictly contraindicated during pregnancy due to the potential risk of viral transmission to the fetus, which could cause congenital defects. The practical nurse must identify this safety risk, withhold the vaccine, and notify the healthcare provider.

Step-by-Step Solution

1
Evaluate the immunization orders against each client's health status and history.
Identify the type of vaccine (live attenuated vs. inactivated) and check for specific contraindications for each client.
To ensure client safety and prevent adverse reactions from contraindicated vaccines.
2
Analyze the pregnant client prescribed the MMR vaccine.
Recognize that the MMR vaccine is a live attenuated vaccine, which is strictly contraindicated during pregnancy.
Live vaccines pose a theoretical risk of viral transmission to the developing fetus, potentially causing congenital defects.
3
Determine the appropriate nursing action.
The PN must withhold the MMR vaccine from the pregnant client and alert the prescribing healthcare provider.
Administering a contraindicated medication or vaccine falls outside safe nursing practice and jeopardizes client safety.

Key Concept

Immunization Contraindications and Pregnancy
Rate this question

Topics

Health Promotion and Disease Prevention

More questions from this topic