The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.

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Question 1 of 5

The nurse assesses a client at 40 weeks gestation and notes regular contractions and cervical dilatation of $6 \mathrm{~cm}$. Which actions by the nurse are important during this stage? Select all that apply.

Correct Answer: D

Rationale: At 40 weeks gestation with 6 cm cervical dilatation, the client is in active labor. Monitoring the fetus (D) is critical to assess for distress via heart rate patterns, a priority in labor management. Administering an epidural (A) requires an order and isn't universally needed. Ensuring hydration (B) supports labor but isn't the top action. Encouraging voiding (C) prevents bladder distension but is secondary. D is chosen. Rationale: Fetal monitoring detects hypoxia or distress, guiding interventions like position changes or delivery, per ACOG standards, outweighing comfort or supportive measures in immediacy during active labor.

Question 2 of 5

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

Correct Answer: D

Rationale: Metabolic alkalosis features high pH (>7.45) and elevated HCO3- (>26 mEq/L) with normal Pco2 (35-45 mm Hg). Option D (pH 7.48, Pco2 40, HCO3- 36) fits this, indicating excess base. A is respiratory acidosis. B is normal. C is compensated. D is correct. Rationale: High HCO3- from vomiting or diuretics causes alkalosis, uncompensated here, per ABG interpretation principles.

Question 3 of 5

A client is scheduled for a computed tomography (CT) of the brain with contrast. When reviewing the client's medical record, what significant finding should the nurse report to the primary healthcare provider before the diagnostic procedure?

Correct Answer: A

Rationale: Metformin (A) is significant before a CT with contrast due to lactic acidosis risk if renal function declines from contrast dye. NPO status (B) isn't critical for brain CT. Gadolinium (C) is MRI-related, not CT. Bowel prep (D) is irrelevant. A is correct. Rationale: Contrast can impair kidneys, exacerbating metformin toxicity, requiring provider adjustment, per radiology safety protocols.

Question 4 of 5

After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?

Correct Answer: B

Rationale: ADH deficiency (diabetes insipidus) post-head injury causes dilute urine (B) due to reduced water reabsorption. Osmolality increases (A) is a result, not a cause. GFR (C) isn't primarily affected. Reabsorption (D) decreases. B is correct. Rationale: Low ADH leads to polyuria with low urine concentration, a key assessment in DI, per endocrine trauma care.

Question 5 of 5

The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of $20 \mathrm{mmHg}$. Which action made by the client is responsible for this condition?

Correct Answer: C

Rationale: ICP of 20 mmHg (elevated) post-hypophysectomy is likely from bending over (C), increasing venous pressure to the brain. Drinking (A) or eating fiber (B) don't directly raise ICP. Knee bending (D) is safe. C is correct. Rationale: Bending elevates intracranial venous return, spiking ICP in a fragile post-surgical state, per neurocare principles, unlike neutral activities.

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