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 A

Explanation

Choice A rationale:

When late decelerations are noted in the fetal heart rate (FHR) tracing, it indicates that the fetal oxygen supply may be compromised. The nurse should first change the client's position, such as moving her to the left lateral position or a hands-and-knees position, to improve uteroplacental blood flow and relieve pressure on the vena cava.

Choice B rationale:

Palpating the uterus to assess for tachysystole is not the priority action when late decelerations are observed. Tachysystole refers to excessively frequent uterine contractions and may contribute to fetal distress, but the immediate concern is addressing the decelerations.

Choice C rationale:

Increasing the client's IV infusion rate may not address the underlying cause of late decelerations. While maintaining hydration is important, it's not the first action to take in this situation.

Choice D rationale:

Administering oxygen at 10 L/min via a non-rebreather mask may be beneficial for the client and fetus, but it is not the first action to take. The nurse should address the position change first to improve oxygenation through better blood flow before considering supplemental oxygen.

A. Hyporeactivity. B. Excessive high-pitched cry. C. Acrocyanosis. D. Respiratory rate of 50/min.

Correct Answer is B

Explanation

Choice A rationale:

Hyporeactivity, or reduced responsiveness to stimuli, is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and not reduced activity.

Choice B rationale:

An excessive high-pitched cry is a common manifestation of neonatal abstinence syndrome. Infants exposed to substances like methadone during pregnancy may experience heightened sensitivity and exhibit a high-pitched cry as a sign of withdrawal.

Choice C rationale:

Acrocyanosis, a bluish discoloration of the hands and feet, is not a specific indicator of neonatal abstinence syndrome. It is a common finding in newborns and often resolves on its own.

Choice D rationale:

A respiratory rate of 50/min is within the normal range for a newborn. It is not an indication of neonatal abstinence syndrome.

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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 caring for a client who is in active labor and notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

Correct Answer is B

Explanation

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A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

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