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.

Choice A rationale:

Baked potato chips are a healthier alternative to regular potato chips because they contain less fat due to the baking process. However, they are still a processed snack and might not be the healthiest option, especially for a school-age group. The high sodium content in many baked chips is also a concern for cardiovascular health.

Choice B rationale:

A milkshake made with whole milk might provide essential nutrients like calcium and protein, but it is also high in calories and can be loaded with sugar, especially if additional sugars or syrups are added. Consuming sugary beverages in excess can contribute to weight gain and dental issues.

Choice C rationale:

"Air-popped popcorn." This is the correct answer. Air-popped popcorn is a healthy whole-grain snack option. It is low in calories, high in fiber, and can be a good source of antioxidants. It is important to note that while air-popped popcorn is healthy, adding excessive butter, salt, or sugar can diminish its nutritional value.

Choice D rationale:

Cheesecake is a rich, high-calorie dessert that is not considered a healthy snack option. It is high in saturated fats, sugars, and calories, making it an occasional treat rather than a suitable healthy snack choice for school-age children.

Lethargy is an expected finding in a child with hypothyroidism. Hypothyroidism slows down the body's metabolism, leading to fatigue, weakness, and lethargy. Children with hypothyroidism may appear sluggish and have low energy levels.