# Situation: A public health nurse works at a Rural Health Unit (RHU) that has a basic emergency obstetric and newborn care (BEmONC) birthing facility. She also takes part in the municipal maternal death review. A 24-year-old woman in her first pregnancy, with no record of any previous tetanus-containing vaccine, received her first dose of tetanus-diphtheria (Td) vaccine at 14 weeks of gestation. She returns at 17 weeks for a routine prenatal visit and is well. What should the nurse do about her second Td dose?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627058  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: A public health nurse works at a Rural Health Unit (RHU) that has a basic emergency obstetric and newborn care (BEmONC) birthing facility. She also takes part in the municipal maternal death review.

A 24-year-old woman in her first pregnancy, with no record of any previous tetanus-containing vaccine, received her first dose of tetanus-diphtheria (Td) vaccine at 14 weeks of gestation. She returns at 17 weeks for a routine prenatal visit and is well. What should the nurse do about her second Td dose?

## 보기

1. Schedule the second dose at 18 weeks of gestation or later **✔ 정답**
2. Schedule the second dose for her first postpartum visit
3. Give the second dose today, at this routine prenatal check-up
4. Schedule the second dose for her next pregnancy instead

**정답: 1**

## 해설

In pregnancy, the second Td dose must be given at least 4 weeks after the first, ideally at least 2 weeks before delivery so that the newborn is protected against neonatal tetanus. Only 3 weeks have passed since the first dose at 14 weeks, so the second dose is due from 18 weeks onward. Later doses then work toward 5 doses for lifetime protection.

## 심화 해설

The interval rule decides the date
This primigravida has no record of any previous tetanus-containing vaccine, so she is starting the tetanus-diphtheria (Td) series in this pregnancy. She received her first dose at 14 weeks and returns at 17 weeks, only 3 weeks later. The minimum interval between the first and second Td doses is 4 weeks, so the second dose cannot be given today. The earliest valid date is 18 weeks of gestation, and the nurse should schedule it then or later. A dose given before the minimum interval may not count toward the series, so the nurse waits until the interval is met.

Why timing matters for the newborn
Td in pregnancy protects two people. The mother forms antibodies against tetanus toxin, and those antibodies cross the placenta to protect the newborn against neonatal tetanus, which can follow unclean cutting or care of the umbilical cord. For this protection to reach the baby, the second dose should ideally be given at least 2 weeks before delivery, so that the mother has time to produce enough antibody. Scheduling the second dose at 18 weeks or soon after fits both rules comfortably: it respects the 4-week minimum interval and comes many weeks before the expected delivery.

| Td dose | When to give |
| --- | --- |
| Td 1 | As early as possible in pregnancy |
| Td 2 | At least 4 weeks after Td 1, ideally at least 2 weeks before delivery |
| Later doses | Continue the series toward 5 doses for lifetime protection |

Why the other choices are unsafe
Giving the second dose today breaks the minimum interval, since only 3 weeks have passed. Moving the dose to the first postpartum visit sounds convenient, but the baby is born before the mother has built enough antibody to transfer, so this newborn would not receive the intended protection against neonatal tetanus. Postponing the dose to a future pregnancy leaves both mother and this baby with only one dose, which does not give reliable protection. Watch out! An option that offers to give the dose "today, so it is not missed" sounds proactive, but it ignores the interval rule.

Exam takeaway
For Td in pregnancy, check two things: at least 4 weeks since the previous dose, and enough time before delivery for the newborn to be protected. The nurse records the first dose, writes the due date of the second dose on the mother's record, and explains why she must return. Later doses in the series, given in future visits or pregnancies, build toward five doses for lifetime protection. Clean delivery and clean cord care remain part of preventing neonatal tetanus alongside immunization.

## 임상 시나리오

Td Immunization in PregnancyScheduling the second dose
The minimum interval between Td 1 and Td 2 is 4 weeks. With Td 1 at 14 weeks, the second dose is due from 18 weeks of gestation onward.

Td 2 should ideally be given at least 2 weeks before delivery so that maternal antibodies cross the placenta and protect the newborn against neonatal tetanus.

Record the due date on the mother's record and explain the return visit. Later doses build toward 5 doses for lifetime protection.

CautionDo not give Td 2 before 4 weeks have passed, and do not delay it until after delivery or a later pregnancy; both leave this newborn unprotected.

## 핵심 개념

- **Td vaccine** — A combined tetanus and diphtheria toxoid given to pregnant women and others to prevent tetanus and diphtheria.
- **Neonatal tetanus** — Tetanus in a newborn, usually from infection of the umbilical stump, often fatal and preventable by maternal immunization.
- **Minimum interval** — The shortest time that must pass between two doses of the same vaccine for the later dose to count.
- **Passive immunity** — Protection a newborn receives from maternal antibodies that cross the placenta during pregnancy.

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