A nurse is caring for a client in active labor.

Admission Assessment.

0200:. Gravida 1, Para 0 at 39 weeks gestation.

Presents with.

contractions occurring every 5 to 6 min, 45 to 60 seconds.

duration.

Cervical examination 4 cm dilated, 50% effaced.

Admit.

to the labor and delivery unit.

Nurses' Notes.

0200:. Admitted to the labor and delivery unit, and reports pain as 7 on a scale.

of O to 10 with contractions.

Cervix 4 cm dilated, 50% effaced,with membranes intact.

0230:. The client reports increasing discomfort with contractions.

Cervix 5. cm dilated, 60% effaced, with membranes intact.

Contractions.

occurring every 5 min, 45 to 60 seconds duration.

0300:. Epidural anesthesia was initiated.

Cervix 7 cm dilated, 70% effaced,. with membranes intact.

Contractions occur every 4 to 5 min,60 seconds duration.

Vital Signs.

0200:. Temperature 36.9° C (98.4° F). Heart rate 86/min.

Respiratory rate 18/min.

BP 118/78 mm Hg. 0230:. Temperature 37° C (98.6° F). Heart rate 88/min.

Respiratory rate 20/min.

BP 120/80 mm Hg. 0300:. Temperature 37.1° C (98.8° F). Heart rate 90/min.

Respiratory rate 18/min.

BP 122/76 mm Hg. The nurse is assuming care for the client at 0305.

For each nursing action, click to specify if the nursing action is essential. contraindicated for the client.

Explanation: Sweet potato is a food that is high in potassium, which is an electrolyte that regulates fluid balance, nerve impulses, and muscle contractions in the body. A medium- sized sweet potato contains about 541 mg of potassium, which is more than 10% of the recommended daily intake for adults. Baked chicken breast, wheat bread, and canned green beans are foods that are low or moderate in potassium, containing less than 300 mg per serving.

Answer is c. Keep visitors at least 6 feet (1.8 m) away from the client.

a. Place the client's soiled bed linens in a biohazard bag outside the client's room: While it is essential to follow standard precautions for handling potentially contaminated linens, soiled bed linens from a client undergoing brachytherapy do not require special handling in a biohazard bag unless contaminated with blood or bodily fluids. Brachytherapy involves the internal placement of radioactive sources near or within the tumor site, but the risk of contamination from bodily fluids is minimal. Therefore, soiled linens can be managed according to standard facility protocols for handling linens.

b. Wear an isolation gown when caring for the client: This option is incorrect because wearing an isolation gown is not necessary for radiation safety during brachytherapy. Radiation exposure is primarily managed through the use of lead aprons, gloves, and other shielding devices when directly handling radioactive sources or being in close proximity to the client during treatment sessions. Isolation gowns are typically used to prevent the spread of infection and are not specifically designed to shield against radiation exposure.

c. Keep visitors at least 6 feet (1.8 m) away from the client: Correct. This action minimizes radiation exposure to visitors, as brachytherapy involves the internal placement of radioactive material near or within the tumor site. Maintaining a distance of at least 6 feet (1.8 meters) from the client helps reduce the risk of radiation exposure to visitors while allowing them to provide support and companionship to the client. Visitors should also be informed about radiation safety precautions and instructed to limit their time spent near the client during treatment.

d. Discard the radioactive source in the client's trash can: This option is incorrect because radioactive sources used in brachytherapy must be handled and disposed of by trained personnel following established radiation safety protocols. Disposing of radioactive material in a client's regular trash can poses significant risks of exposure to others and is not permitted. Proper disposal procedures for radioactive sources involve packaging them in approved containers and returning them to the facility's radiation safety department for appropriate disposal or recycling.

In summary, the correct answer is c because keeping visitors at least 6 feet (1.8 meters) away from the client helps minimize their radiation exposure during brachytherapy, which involves the internal placement of radioactive material near or within the tumor site. This action aligns with radiation safety principles and helps protect both the client and visitors from unnecessary radiation exposure.