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:

Hyporeactivity is not typically associated with neonatal abstinence syndrome (NAS) NAS is characterized by increased irritability and signs of withdrawal, which are opposite to a hypo- reactive state.

Choice B rationale:

An excessive high-pitched cry is a hallmark sign of neonatal abstinence syndrome. Babies exposed to drugs like methadone during pregnancy can experience withdrawal symptoms, including a distinct high-pitched cry.

Choice C rationale:

Acrocyanosis, a bluish discoloration of the extremities, is a common finding in newborns and is not specific to NAS. It is caused by immature peripheral circulation and usually resolves on its own.

Choice D rationale:

A respiratory rate of 50/min is within the normal range for a newborn and is not a sign of neonatal abstinence syndrome. NAS symptoms are related to drug withdrawal and not respiratory issues.

A. Hormonal changes with a rapid decline in estrogen and progesterone levels. B. Increased social support systems. C. High self-esteem. D. Mother of two other children.

Correct Answer is A

Explanation

Choice A rationale:

Hormonal changes play a significant role in postpartum depression. After childbirth, there is a rapid decline in estrogen and progesterone levels, which can lead to mood fluctuations and depressive symptoms. Understanding this hormonal aspect is crucial for the nurse to address postpartum depression risk factors.

Choice B rationale:

Increased social support systems would be considered a protective factor against postpartum depression rather than a risk factor. Having strong social support can help mitigate the risk of developing postpartum depression.

Choice C rationale:

High self-esteem is not typically a risk factor for postpartum depression. In fact, individuals with higher self-esteem may be more resilient in coping with the challenges of postpartum period.

Choice D rationale:

Being a mother of two other children is not inherently a risk factor for postpartum depression. While having multiple children can be demanding, it does not directly increase the risk of developing postpartum depression. The hormonal changes and individual circumstances play more significant roles.

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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 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?

Correct Answer is B

Explanation

A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?

Correct Answer is A

Explanation

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