A nurse is using Naegele's rule to calculate the estimated due date of a client who reports that the first day of their last menstrual cycle was July 21st.
Which of the following should the nurse document as the client's expected due date?

Choice A rationale

Fundal height measurement is a simple clinical tool used to estimate gestational age and monitor fetal growth. The correct technique involves using a non-stretchable measuring tape to measure the distance in centimeters from the upper border of the symphysis pubis (a fixed bony landmark) to the highest point of the uterine fundus.

Choice B rationale

A full bladder can artificially elevate the uterine fundus, leading to an overestimation of the fundal height and an inaccurate assessment of fetal growth and gestational age. The nurse should instruct the client to empty their bladder before the measurement is taken to ensure the most reliable result.

Choice C rationale

The fundal height measurement is taken vertically, along the midline of the client's abdomen, from the symphysis pubis to the fundus. Measuring horizontally would not provide a clinically relevant or reproducible measure for assessing fetal growth or comparing against expected gestational age measurements.

Choice D rationale

Fundal height measurement should be performed with the client in the supine position with the knees slightly flexed. Placing the client in the left-lateral position is done to prevent supine hypotension syndrome (aorta-caval compression) but would make a standardized and accurate fundal height measurement impossible to obtain.

Choice A rationale

Body tremors are a key indicator of central nervous system (CNS) hyperirritability, which is a major component of neonatal abstinence syndrome (NAS) following in utero exposure to opioids like heroin. The newborn's immature CNS struggles to adapt after the abrupt cessation of the drug, leading to uncoordinated, jerky movements, exaggerated reflexes, and generalized irritability.

Choice B rationale

Tachypneic respirations (respiratory rate greater than 60 breaths/min) are a common sign of NAS. This occurs due to the dysregulation of the autonomic nervous system and increased metabolic rate associated with the hyperirritable state. Other respiratory signs include flaring, retractions, and frequent yawning or sneezing, reflecting CNS overstimulation.

Choice C rationale

The hyperirritability of the CNS in NAS typically leads to increased and exaggerated reflexes (hyperreflexia), such as a hyperactive Moro reflex, not decreased reflexes. Decreased reflexes would suggest CNS depression, which is characteristic of acute opioid intoxication, not the withdrawal state of NAS.

Choice D rationale

Newborns experiencing NAS are characterized by CNS hyperstimulation, leading to excessive wakefulness, irritability, and an inability to be consoled, often referred to as hyperactivity or agitation. Extreme lethargy and hypoactivity are signs of CNS depression or severe illness, which is contrary to the expected presentation of NAS.

Choice E rationale

The hyper-responsiveness of the newborn's CNS in NAS causes a characteristic high-pitched, non-stop, inconsolable crying. This shrill, distressed cry is due to the sustained state of irritability and neurological overstimulation, representing a significant manifestation of withdrawal symptoms that is distressing to both the newborn and the caregivers.