Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at a clinic is counseling a client who has a positive pregnancy test. The first day of the client's last menstrual period was November 9. Use Nägele's rule to calculate the estimated date of delivery.
(Use the MMDD format with four numerals and no spaces or punctuation.)
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Full Explanation
To calculate the estimated date of delivery using Nägele's rule, follow these steps:
-Add 7 days to the first day of the last menstrual period. In this case, November 9 + 7 days = November 16.
- Subtract 3 months from the month of the last menstrual period. In this case, November - 3 months = August.
The estimated date of delivery is August 16
The rationale for this rule assumes that the average menstrual cycle is 28 days long and that ovulation occurs on day 14 of the cycle. Therefore, adding 7 days to the first day of the last menstrual period approximates the date of conception. Subtracting 3 months from the month of the last menstrual period adjusts for the difference between the lunar calendar (13 months) and the Gregorian calendar (12 months).
Similar Questions
A nurse is preparing to collect a blood specimen from a newborn via heelstick. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
A. Place a heel warmer on the newborn's heel.
B. Confirm the identity of the newborn.
C. Apply pressure to the puncture site with a dry gauze pad.
D. Label the specimen per facility protocol.
E. Clean the puncture site with an antiseptic cleanser.
Full Explanation
This sequence ensures proper identification, infection control, specimen collection, and safety for the newborn.
Choice A rationale:
The nurse should place a heel warmer on the newborn's heel for 3 to 5 minutes before the heelstick to increase blood flow and facilitate collection.
Choice B rationale:
The nurse should confirm the identity of the newborn before collecting any specimen to ensure patient safety and avoid errors.
Choice C rationale:
The nurse should apply pressure to the puncture site with a dry gauze pad to stop bleeding and promote clotting.
Choice D rationale:
The nurse should label the specimen per facility protocol to ensure accurate identification and processing.
Choice E rationale:
The nurse should clean the puncture site with an antiseptic cleanser to prevent infection and reduce contamination of the specimen.
A nurse is assessing a client who is 1 week postpartum. Which of the following locations should the nurse palpate to assess the client's fundus? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A. A
This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
B. B
This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
C. C
One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.
Full Explanation
Choice A rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation).
Choice B rationale: This is incorrect because at about one hour after child birth the fundus should be around the belly button (where it was at 20 weeks of gestation). It then decreases steadily at approximately 1 cm every 24 hours.
Choice C rationale: One-week post-partum, the fundal height should be about 7 cm below the umbilicus (belly button). This means that the uterus is still larger than normal, but it is contracting and healing. The fundal height may vary depending on factors such as the size and position of the baby, the amount of amniotic fluid, and the mother's body type.
A nurse is providing teaching to a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following client statements indicates an understanding of the teaching?
A. "I need to make sure other members of my family get immunized against the disease."
Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.
B. "Since I will stay in the hospital, I should begin the process of selling my home."
Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.
C. "I will need to begin hospice care immediately."
Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.
D. "I would like to talk to someone about creating a living will."
Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.
Full Explanation
Choice A rationale:
Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.
Choice B rationale:
Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.
Choice C rationale:
Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.
Choice D rationale:
Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.