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A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

February 1

February 8

February 15

February 22

Answer and Explanation

The Correct Answer is C

February 15.

A. February 1 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.
B. February 8 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, minus seven days is February 8, plus one year is February 8 of the following year.
C. February 15 is the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus one year is February 15 of the following year.
D. February 22 is not the correct EDB according to Nägele's rule. Nägele's rule states that to estimate the EDB, subtract three months from the LMP and add seven days and one year. Therefore, May 8 minus three months is February 8, plus seven days is February 15, plus seven days is February 22, plus one year is February 22 of the following year.

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Correct Answer is C

Explanation

- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.

- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.

- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\

- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.

A. Insert air in the tube and listen for gurgling sounds in the epigastric area B. Aspirate contents from the tube and verify the pH level C. Review the medical record for previous x-ray verification of placement D. Auscultate the lungs for adventitious breath sounds

Correct Answer is B

Explanation

Aspirate contents from the tube and verify the pH level.

A. This is an incorrect action. Inserting air in the tube and listening for gurgling sounds in the epigastric area is not a reliable method to confirm NG tube placement, as it can produce falsepositive results due to air entering the stomach or intestines.
B. This is a correct action. Aspirating contents from the tube and verifying the pH level is a valid method to confirm NG tube placement, as gastric contents typically have a pH of less than 5.5, while intestinal or respiratory contents have a higher pH.
C. This is an incorrect action. Reviewing the medical record for previous x-ray verification of placement is not sufficient to confirm NG tube placement, as the tube can migrate or become dislodged after insertion. X-ray verification should be done initially and whenever there is doubt about the tube's position.
D. This is an incorrect action. Auscultating the lungs for adventitious breath sounds is not a specific method to confirm NG tube placement, as it can indicate other conditions such as pneumonia or pulmonary edema. It can also miss signs of respiratory complications due to NG tube misplacement, such as pneumothorax or bronchial obstruction.

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A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)?

Nursing Test Bank

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