A 25-year-old female comes to the clinic for a routine well-woman exam.
Which statement would indicate that the patient requires additional instruction about breast self-examination?

"I should also feel in my armpit area while performing breast examination.”.

"Yellow discharge from my nipple is normal if I am having my period.”.

"I should check my breast at the same time each month, like after my period.”.

"I should check each breast in a set way, such as in circular motion.”.

Answer and Explanation

The Correct Answer is B

Choice B rationale

Any nipple discharge in a non lactating woman, especially if it is yellow, bloody, or serosanguinous, is abnormal and requires further investigation by a healthcare provider. While some hormonal changes occur during the menstrual cycle, spontaneous discharge is not a standard finding and could indicate an intraductal papilloma, infection, or malignancy. Patients must be taught that the only normal nipple discharge is breast milk during or after pregnancy. Recognizing and reporting abnormal discharge is a critical component of breast health education.

Choice C rationale

Performing a breast self examination at the same time each month, specifically several days after the menstrual period ends, is the correct technique. During this time, hormonal stimulation of the breast tissue is at its lowest, meaning the breasts are less likely to be tender or lumpy due to normal cyclic changes. This consistency allows the woman to become familiar with her normal breast tissue, making it easier to identify any new or unusual changes that may occur.

Choice D rationale

Using a systematic approach, such as a circular motion, vertical strip, or wedge pattern, ensures that all breast tissue, including the area under the nipple, is thoroughly palpated. Consistency in the method used helps the patient cover the entire breast area without missing any spots. Teaching a set way to perform the exam increases the likelihood of detecting small changes in the consistency or structure of the breast tissue, which is the primary goal of the self examination.

Choice A rationale

The axillary area, or armpit, contains the Tail of Spence, which is an extension of breast tissue where a significant percentage of breast cancers can develop. Including this area in a self examination is vital because lymph nodes in the axilla are often the first site of metastasis for breast malignancies. Patients should be instructed to feel for any lumps, thickening, or hard knots in the armpit to ensure a comprehensive assessment of all potential areas where breast pathology might arise.

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Correct Answer is B

Explanation

Choice A rationale

Placing a newborn flat immediately after a feeding session increases the hydrostatic pressure against the lower esophageal sphincter. In infants, this sphincter is often physiologically immature, leading to the retrograde flow of gastric contents into the esophagus. Keeping the infant flat facilitates this regurgitation and increases the risk of aspiration. Elevating the head allows gravity to assist in keeping milk within the stomach cavity until the pyloric sphincter can process the bolus.

Choice B rationale

Regurgitation in neonates is frequently caused by swallowed air that creates pressure within the stomach. Periodic burping during and after feedings allows for the controlled release of this air, preventing it from forcing milk upward. Maintaining the infant in an upright or slightly elevated position for 20 to 30 minutes post-feeding utilizes gravity to keep gastric contents at the base of the stomach, thereby significantly reducing the frequency and volume of spit-up episodes.

Choice C rationale

Regurgitation of small amounts of milk is a normal physiological occurrence in newborns due to a short esophagus and a relaxed cardiac sphincter. It is rarely an indication of an allergy to human milk, which contains species-specific proteins that are highly digestible. Switching to formula unnecessarily exposes the infant to foreign bovine proteins and lacks the immunological benefits of colostrum and breast milk. True milk protein allergies typically present with systemic symptoms like rash or bloody stools.

Choice D rationale

Feeding a newborn larger volumes less frequently is counterproductive and dangerous. The neonatal stomach capacity is very limited, approximately 5 mL to 7 mL on day one, and overdistension of the stomach wall triggers the vomiting reflex and increases the likelihood of reflux. Smaller, more frequent feedings align with the natural gastric emptying time and metabolic needs of the infant. Overfilling the stomach exacerbates the anatomical predisposition for spitting up and can cause significant abdominal discomfort.

A. Assist the patient in emptying her bladder. B. Assess the blood pressure and pulse. C. Evaluate the lochia. D. Notify the physician of an impending hemorrhage.

Correct Answer is A

Explanation

Choice A rationale

A soft, boggy uterus in the postpartum period is often caused by bladder distension. A full bladder displaces the uterus upward and to the side, preventing efficient myometrial contraction. This uterine relaxation increases the risk of bleeding. Assisting the patient to void allows the uterus to return to the midline and contract effectively. This is a common and easily reversible cause of uterine atony that should be addressed before considering more invasive medical treatments.

Choice B rationale

Monitoring blood pressure and pulse is necessary to evaluate the patient's hemodynamic status, as a soft uterus can lead to hemorrhage. However, physiological compensation in the early postpartum period can mask signs of blood loss until it is quite severe. While these parameters provide a baseline for the severity of the situation, they do not correct the underlying problem of a boggy uterus. Uterine tone must be restored first to prevent the vital signs from deteriorating.

Choice C rationale

Evaluating the lochia helps determine the amount and characteristics of vaginal discharge, which is an indicator of uterine healing and potential hemorrhage. Increased lochia often accompanies a boggy uterus. While this assessment is part of the overall postpartum evaluation, it does not directly treat the cause of the bogginess. The nurse's priority is to implement an intervention that encourages uterine firmness, such as emptying the bladder or performing massage, rather than just observing the output.

Choice D rationale

Notifying the physician is required if the uterus remains boggy after initial nursing interventions or if bleeding is excessive. However, the nurse should first attempt to resolve the issue through bladder emptying or fundal massage. Reporting a boggy uterus without first checking for bladder distension or attempting to firm the fundus is premature. Effective nursing practice involves performing immediate, independent actions to stabilize the patient before escalating the situation to the physician for further orders.

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A 25-year-old female comes to the clinic for a routine well-woman exam. Which statement would indicate that the patient requires additional instruction about breast self-examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new mother is concerned because her 1-day-old infant spits up a small amount after feeding. She asks the nurse how to prevent this. Which instruction should the nurse provide?

Correct Answer is B

Explanation

A nurse just assumed her shift and is preparing to assess a client's uterine fundus in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which initial nursing action would be most appropriate?

Correct Answer is A

Explanation

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A 25-year-old female comes to the clinic for a routine well-woman exam.
Which statement would indicate that the patient requires additional instruction about breast self-examination?