Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. The nurse uses Naegele's Rule to calculate the correct EDD:
A. April 27, 2016
Choice A: April 27, 2016 Reason: This date is incorrect because it does not follow Naegele’s Rule. Naegele’s Rule involves adding 7 days to the first day of the last menstrual period (LMP) and then subtracting 3 months. Adding 7 days to May 4, 2015, gives us May 11, 2015. Subtracting 3 months from May brings us to February, not April.
B. April 11, 2016
Choice B: April 11, 2016 Reason: This date is also incorrect for the same reason as Choice A. It does not follow Naegele’s Rule. Adding 7 days to May 4, 2015, gives us May 11, 2015. Subtracting 3 months from May brings us to February, not April.
C. February 27, 2016
Choice C: February 27, 2016 Reason: This date is closer but still incorrect. Adding 7 days to May 4, 2015, gives us May 11, 2015. Subtracting 3 months from May brings us to February. However, the correct date should be February 11, not February 27.
D. February 11, 2016
Choice D: February 11, 2016 Reason: This is the correct date. Using Naegele’s Rule, we add 7 days to the first day of the last menstrual period (May 4, 2015), which gives us May 11, 2015. Then, we subtract 3 months, which brings us to February 11, 2016. This is the correct Estimated Due Date (EDD).
This question is an excerpt from Nurse Dive's nursing test bank - ATI Maternity Exam - Proctored Exam 2. Take the full exam now
Full Explanation
The correct answer is: April 11, 2016
Choice A: April 27, 2016
Reason: Using Naegele’s Rule, the estimated date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period (LMP). For an LMP of May 4, 2015:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 27, 2016, is incorrect because it does not follow the correct calculation steps.
Choice B: April 11, 2016
Reason: Following Naegele’s Rule:
- Add one year: May 4, 2016
- Subtract three months: February 4, 2016
- Add seven days: February 11, 2016
April 11, 2016, is the correct EDD as it accurately follows the calculation steps.
Choice C: February 27, 2016
Reason: This date is incorrect because it does not follow the correct calculation steps of Naegele’s Rule. The correct EDD should be in April, not February.
Choice D: February 11, 2016
Reason: This date is also incorrect. While it follows the initial steps of Naegele’s Rule, it does not account for the full calculation, which should result in an April date, not February.
Similar Questions
A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform?
A. Immediately report the situation to the client's provider and prepare the client for induction of labor.
Reporting the situation and preparing the client for induction of labor is not the first action to take. Turning the client onto her left side is the initial intervention to stimulate fetal movements.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring.
Encouraging the client to walk around without the monitoring unit is not appropriate in this situation, as the NST requires continuous monitoring of the fetal heart rate.
C. Turn the client onto her left side.
During a nonstress test (NST), the nurse monitors the fetal heart rate in response to fetal movements. Absence of fetal movements for 15 minutes can be concerning and might not provide adequate information for the NST. The first intervention should be to encourage fetal movement by turning the client onto her left side, which can improve blood flow to the uterus and increase fetal activity.
D. Offer the client a snack of orange juice and crackers
Offering the client a snack of orange juice and crackers might be done as a noninvasive intervention to encourage fetal movements, but turning the client onto her left side is more effective and should be done first.
Full Explanation
A. Immediately report the situation to the client's provider and prepare the client for induction of labor. This option is premature. The absence of fetal movement for 15 minutes during a nonstress test does not immediately indicate a need for induction of labor. Other less invasive interventions should be attempted first to stimulate fetal movement.
B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. While movement can sometimes stimulate fetal activity, removing the monitoring unit is not advisable during a nonstress test. Continuous monitoring is essential to accurately assess the fetal heart rate and movement.
C. Turn the client onto her left side.This position can improve uteroplacental blood flow and may help stimulate fetal movement. However, it is not the most effective initial intervention compared to offering a snack, which can provide a quicker response.
D. Offer the client a snack of orange juice and crackers. This is the correct intervention. The sugar in the orange juice can provide a quick source of energy to the fetus, potentially stimulating movement. Additionally, the act of eating can sometimes prompt fetal activity.
A nurse is providing dietary education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?
A. "I should not drink alcoholic beverages during my pregnancy."
"I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
B. "I should drink about 2 liters of fluid each day."
"I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
C. "I can have a moderate amount of caffeine daily."
"I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
D. "I should increase my intake of all kinds of fish throughout my pregnancy."
During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
Full Explanation
Choice A: "I should not drink alcoholic beverages during my pregnancy." Correct, as alcohol consumption during pregnancy can lead to fetal alcohol spectrum disorders and other adverse outcomes.
Choice B: "I should drink about 2 liters of fluid each day." Correct, as adequate hydration is essential during pregnancy.
Choice C: "I can have a moderate amount of caffeine daily." Correct, as moderate caffeine consumption is generally considered safe during pregnancy (around 200300 mg per day).
Choice D: During pregnancy, certain fish types can be high in mercury, which can be harmful to the developing fetus. Fish with high mercury levels should be limited or avoided during pregnancy.
A nurse is caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?
A. Temperature 38.2°C (100.8°F)
Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B. The client reports reduced sensation of the lower extremities.
Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C. The client reports generalized itching.
Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D. Blood pressure 80/52 mm Hg
Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.
Full Explanation
A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.