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 C

Explanation

Choice A rationale:

Monitoring fluid intake is important for any newborn, but it is not the priority intervention for a small for gestational age (SGA) newborn. SGA infants are at risk of hypoglycemia due to limited glycogen stores, and monitoring blood glucose levels is crucial in identifying and managing hypoglycemia.

Choice B rationale:

Monitoring axillary temperature is essential for all newborns to assess their thermoregulation. However, it is not the priority intervention for an SGA newborn. Hypoglycemia is a more immediate concern and must be addressed promptly.

Choice C rationale:

Monitoring blood glucose levels is the priority intervention for an SGA newborn. As mentioned earlier, SGA infants are at higher risk of hypoglycemia, which can lead to serious complications if not managed appropriately. By monitoring blood glucose levels, the nurse can detect and address hypoglycemia early.

Choice D rationale:

Monitoring weight is important for tracking the growth and development of the newborn, but it is not the priority intervention in this scenario. The immediate concern for an SGA newborn is their blood glucose levels.

A. Change the client's position. B. Palpate the uterus to assess for tachysystole. C. Increase the client's IV infusion rate. D. Administer oxygen at 10 L/min via a nonrebreather mask.

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.

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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 planning care for a newborn who is small for gestational age (SGA) Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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