Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
A healthy one-year-old, accompanied by his mother, is in for a well-child visit. He's due to receive routine immunizations for a child his age. His mom mentions that she's about six weeks pregnant and read that, “I know he should get the chicken pox and the German measles vaccines today. Since I'm pregnant, is this safe?” The NP considers the following:
A. Neither vaccine contains live virus and both can be given today.
B. Both vaccines contain live virus that the child will not shed and he can receive these immunizations today.
C. The vaccines contain live virus and should be delayed until the mom is out of the first trimester of pregnancy.
D. Due to the mom's pregnancy, these vaccines should be delayed until after she gives birth.
The correct answer here is B. Both vaccines contain live virus that the child will not shed, and he can receive these immunizations today.
Where should we start? First, let's ascertain what kind of question this is. Given we're being asked to assess the safety or not of a child receiving a vaccine when the mom is pregnant, this is an intervention/plan question.
Now for some background information: Rubella, a.k.a. German measles and varicella, a.k.a. chicken pox, are both vaccine-preventable diseases. Indeed, the vaccines against these conditions are so effective that many healthcare providers, let alone parents and caregivers, have seen neither. This is a stark contrast to the pre-vaccine era, where both of these illnesses were seen in nearly all children. Sometimes you might even encounter a very outdated term that every now and again will crop up in the healthcare literature, and it will be noted in adults born prior to 1959. There'll be a notation that this person had, “the usual childhood illnesses,” which included measles, mumps, chicken pox, German measles, and quite often whooping cough. Immunization against rubella in this country began in the 1960s and against varicella in the 1990s. This is the reason why we even have healthcare providers who have never seen a child with rubella, never seen a child with varicella. And as an aside, where I practice, I am, shall we say, among one of the older providers. And quite often when I'm in clinic, I'll hear a gentle little knock on my exam room door and it's one of my significantly lot younger colleagues asking me if I will come and take a look at a child with a rash. And one of the reasons they will ask me is because I know what chickenpox looks like. I know what measles looks like. I know what rubella looks like because of my age.
Rubella is actually a very mild illness, and it's one of these vaccines that we give not so much to protect the child, but to protect pregnant women. Very little risk of complication in a child having rubella. However, the greatest risk from this infection is during pregnancy, particularly with first trimester maternal rubella, which can confer an 80% rate of congenital rubella syndrome. The end result of congenital rubella syndrome can include pregnancy loss, miscarriage, stillbirth, and severe congenital anomalies, including blindness, deafness, and profound developmental disability in the offspring of women that contract rubella during pregnancy. Prevention of rubella can be achieved by the highly effective MMR vaccine where the R in the MMR stands for rubella. This is a live virus vaccine. It's not typically given during pregnancy due to the theoretical, but never demonstrated, risk of the fetus being exposed to this live virus vaccine in the mom developing congenital rubella syndrome.
Varicella, or chickenpox, is caused by the varicella zoster virus. This is a highly contagious virus transmitted by respiratory, droplet, and contact with open lesions. Chickenpox can be serious, particularly in infants, the immunocompromised, and in adults. Complication of varicella infection can include bacterial infection of skin lesions, pneumonia, encephalitis, toxic shock syndrome, and Reye’s syndrome. Reye’s syndrome, which you no doubt have heard about, is a life-threatening disease, particularly for people who take aspirin during the viral infection. Varicella is the worst of the lot of all the viral infections. The most dangerous scenario to take aspirin in. Congenital varicella syndrome is rare, but it can lead to congenital anomalies, if the mom becomes infected in early pregnancy up to about 20 weeks gestation. Varicella immunization, which is a live virus vaccine, is protective against contracting the disease, as well as avoiding severe disease if infection occurs. And that's one thing, when the varicella vaccine very first came out, we were only giving one shot. And what was happening was some kids were still getting mild cases of varicella that now they get two immunizations against varicella. And that issue has largely resolved. As with all live virus vaccines, varicella immunization is not advised during pregnancy due to the theoretical, but not demonstrated, risk of congenital varicella syndrome in the offspring.
With that in mind, let's take a look at the question and the potential answers.
A healthy one-year-old, accompanied by his mother, is in for a well-child visit. He's due to receive routine immunizations for a child his age. His mom mentions that she's about six weeks pregnant and read, “I know he should get the chicken pox and the German measles vaccines today. Since I'm pregnant, is this safe?” The NP considers the following:
A. Neither vaccine contains live virus and both can be given today. First, please note the format of this question where the option has two pieces of information, and the two pieces are neither vaccine contain live virus and both can be given today. So that's what I mean by the two pieces of information. With questions in a format like this, both must be correct for the answer to be correct. As we just covered, this choice would be incorrect as these are both live virus vaccines. We will delve into whether these vaccines are okay to give today or not. But we should reject this option right out of hand because one part is inaccurate. So, A is, of course, incorrect.
B. Both vaccines contain live virus that the child will not shed, and he can receive these immunizations today. This is the correct answer. Live virus vaccines are not shed by the recipient. While neither of these vaccines should be offered to mom, if needed, during her pregnancy, her toddler can receive these shots today.
C. So B is our correct answer. We’re going to go over C and D now.
C. The vaccines contain live virus and should be delayed until mom is out of the first trimester of pregnancy. This is, of course, incorrect due to the lack of viral shedding. At the same time, you'll often be asked this question in practice by understandably concerned parents and caregivers of the little ones. Having accurate information is critical to safe and effective practice.
What about now Option D, which we obviously know is incorrect? Option D due to the mom's pregnancy, these vaccines should be delayed until after she gives birth. This violates a basic vaccination principle of, “immunizations delayed can mean immunizations denied.” In other words, whatever barrier to vaccination is put up, that immunization might never be given.
Key takeaway: Knowledge of the very few vaccine contraindications, and knowing how to avoid common vaccine safety misconceptions, are keys to safe practice in NP or success.
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