433) The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? 1.The skin 2.Urinary output 3.Wound drainage 4.The gastrointestinal tract Correct Answer: 1,Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses. 434) The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1.Variability 2.Accelerations 3.Early decelerations 4.Variable decelerations Correct Answer: 4,Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction. 435) A client receiving a cleansing enema complains of pain and cramping. The nurse should take which corrective action? 1.Discontinue the enema. 2.Reassure the client, and continue the flow. 3.Raise the enema bag so that the solution can be completed quickly. 4.Clamp the tubing for 30 seconds, and restart the flow at a slower rate. Correct Answer: 4,Enema fluid should be administered slowly. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore, options 1, 2, and 3 are incorrect actions.