During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

Both breasts have many nodules in the upper outer quadrants.

The client states she has bilateral breast tenderness with palpation.

The left breast is slightly larger than the right breast.

An irregularly shaped, nontender lump is palpable in the right breast.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Having many nodules in the upper outer quadrants of the breasts is a common and expected finding in breast tissue and is not necessarily a cause for concern.

Choice B rationale:

Bilateral breast tenderness with palpation can be a normal finding, especially in young women with hormonal changes. It is not of immediate concern unless it is accompanied by other worrisome symptoms.

Choice C rationale:

Slight differences in breast size are often normal and not necessarily concerning, especially in young women whose breast development may not have fully stabilized.

Choice D rationale:

An irregularly shaped, nontender lump palpable in the breast raises concerns for a potential breast mass or tumor. This finding requires further evaluation and investigation by a healthcare provider to determine its nature and possible malignancy. Early detection of breast abnormalities is crucial for timely management and improved outcomes.

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Correct Answer is B

Explanation

Choice A rationale:

Hypertonia (increased muscle tone) is not a manifestation of hypoglycemia in a newborn. Instead, hypotonia (decreased muscle tone) is more characteristic.

Choice B rationale:

This is the correct choice. Jitteriness is a common sign of hypoglycemia in a newborn. It may be accompanied by other symptoms like poor feeding, tremors, and irritability.

Choice C rationale:

Acrocyanosis (bluish discoloration of the hands and feet) is a normal finding in newborns and is not specifically associated with hypoglycemia.

Choice D rationale:

Generalized petechiae (small red or purple spots on the skin caused by bleeding under the skin) are not indicative of hypoglycemia but may be associated with other medical conditions.

A. Keep the newborn dressed while receiving phototherapy. B. Apply lotion to the skin twice daily. C. Maintain an eye mask over the newborn's eyes. D. Maintain the phototherapy during blood draws.

Correct Answer is C

Explanation

Choice A rationale:

Keeping the newborn dressed while receiving phototherapy is not recommended because the baby's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Direct exposure to light helps break down the excess bilirubin in the baby's blood, leading to its excretion.

Choice B rationale:

Applying lotion to the skin twice daily is contraindicated during phototherapy. Lotions and creams can block the light from reaching the skin and hinder the therapeutic effects of the phototherapy. The baby's skin should remain exposed to the light for optimal treatment.

Choice C rationale:

Maintaining an eye mask over the newborn's eyes is essential during phototherapy. The eyes are sensitive to light, and prolonged exposure to the phototherapy light can lead to eye damage. Using an eye mask protects the baby's eyes while allowing the rest of the body to receive the necessary light treatment.

Choice D rationale:

Maintaining the phototherapy during blood draws is crucial to ensure continuous treatment of hyperbilirubinemia. Interrupting the phototherapy during blood draws might result in the rebound of bilirubin levels, which can be harmful to the baby.

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During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

Correct Answer is B

Explanation

A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

Correct Answer is C

Explanation

A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?

The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? Select all that apply.

A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take?

A nurse is teaching a client who is to start using a diaphragm for contraception. Which of the following client statements indicates an understanding of the teaching?

A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?