A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also informs that she performs her breast self-examination (BSE) on the first day of every month. Which action should the nurse implement in response to the clients statements?

Remind the client that is also important to schedule an annual mammogram.

Refer the client to a nurse practitioner for an in-depth review of the BSE procedure.

Instruct the client to continue with her regular monthly exams as she is doing.

Encourage the client to perform BSE 2 to 3 days after her menstrual period ends.

Answer and Explanation

The Correct Answer is D

A. Remind the client that it is also important to schedule an annual mammogram: For a 20-year-old woman with no significant risk factors, an annual mammogram is not typically recommended. Mammograms are usually suggested for women starting at age 40, or earlier for those with risk factors.

B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure: While BSE education is important, a referral to a nurse practitioner for an in-depth review may not be necessary if the client is already performing the examination correctly.

C. Instruct the client to continue with her regular monthly exams as she is doing: Performing a BSE on the first day of the menstrual period may not be ideal due to breast tenderness during that time. The nurse should recommend a more optimal time for the examination.

D. Encourage the client to perform BSE 2 to 3 days after her menstrual period ends: The best time to perform a BSE is when the breasts are least likely to be swollen or tender, typically 2 to 3 days after the menstrual period ends. This allows for more accurate assessment and decreases discomfort.

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Correct Answer is C

Explanation

A. Morning sickness: While morning sickness (nausea and vomiting) is a common symptom in early pregnancy, it is not the most reliable sign of pregnancy, as it can also occur with other conditions.

B. Hegar's sign: Hegar's sign, which is the softening of the lower uterine segment, is a probable sign of pregnancy but requires a clinical exam for confirmation. It is not as definitive as amenorrhea.

C. Amenorrhea: Amenorrhea, or the absence of menstruation, is one of the most reliable early signs of pregnancy. A missed period is often the first indication that a woman may be pregnant.

D. Breast tenderness: While breast tenderness can occur during pregnancy, it can also happen due to other factors such as hormonal changes, making it a less definitive sign of pregnancy compared to amenorrhea.

A. Increase food intake by 300 to 400 calories/day. B. Maintain current protein intake C. Take iron and calcium supplements daily. D. Take folic acid supplements daily. E. Gain no more than 15 pounds (6.8 kg) during the pregnancy.

Correct Answer is ["A","C","D"]

Explanation

A. Increase food intake by 300 to 400 calories/day: Pregnant adolescents need to increase their caloric intake to support fetal growth and their own developing bodies. The recommended increase is 300 to 400 calories per day.

B. Maintain current protein intake: Protein needs should actually increase during pregnancy, not remain the same, to support fetal growth and tissue development. Adolescents need to focus on increasing their protein intake during pregnancy.

C. Take iron and calcium supplements daily: Iron and calcium supplements are often recommended during pregnancy to support maternal health and fetal development. Iron helps prevent anemia, and calcium supports bone development.

D. Take folic acid supplements daily: Folic acid is essential in pregnancy to prevent neural tube defects and support cell growth. It is crucial for all pregnant women, including adolescents, to take folic acid supplements daily.

E. Gain no more than 15 pounds (6.8 kg) during the pregnancy: The recommended weight gain during pregnancy depends on pre-pregnancy BMI and other factors. For pregnant adolescents, weight gain may need to be higher than 15, typically 25-35 pounds to accommodate both fetal growth and maternal development.

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Naxlex Comprehensive Predictor Exams

A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant?

Correct Answer is C

Explanation

Which content should the nurse plan to include in a nutrition class for pregnant adolescents? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

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Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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