When performing a clinical breast examination, which would the nurse do first?

Inspect the breasts.

Palpate the axillary area.

Compress the nipple for a discharge.

Palpate the breasts.

Answer and Explanation

The Correct Answer is A

A. Inspect the breasts:

Inspecting the breasts visually is usually the first step in a clinical breast examination. The nurse observes the size, shape, symmetry, and skin characteristics of the breasts, including any visible abnormalities such as dimpling, puckering, or changes in skin texture or color.

B. Palpate the axillary area:

Palpating the axillary (underarm) area is typically done after inspecting the breasts. This allows the nurse to assess for any enlarged lymph nodes or palpable masses in the axillary region, which could indicate pathology or breast cancer metastasis.

C. Compress the nipple for a discharge:

If there are concerns about nipple discharge, this step may follow breast palpation. By gently compressing the nipple, the nurse can assess for any abnormal discharge, such as bloody or spontaneous discharge, which may warrant further investigation.

D. Palpate the breasts:

Palpating the breasts is usually performed after visual inspection and axillary palpation. During breast palpation, the nurse systematically examines each breast using circular motions with varying pressure to detect any lumps, masses, or areas of tenderness. This thorough palpation helps identify any abnormalities within the breast tissue.

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Correct Answer is B

Explanation

A. "You'll probably have a cesarean birth to prevent exposing your newborn."

This statement suggests a specific intervention without addressing the broader context of HIV management during pregnancy. While a cesarean birth may be recommended in certain cases to reduce the risk of vertical transmission of HIV, it is not the only or primary measure taken. Antiretroviral therapy (ART) is typically the mainstay of treatment during pregnancy to suppress viral load and reduce transmission risk.

B. "Antiretroviral medications are available to help reduce the risk of transmission."

This response provides accurate information about the use of antiretroviral medications during pregnancy to reduce the risk of mother-to-child transmission of HIV. ART is a critical component of HIV management in pregnant women and has been shown to significantly decrease the risk of vertical transmission when used appropriately.

C. "Wait until after the infant is born, and then something can be done."

This statement is not appropriate because it suggests delaying action until after the infant is born, which may increase the risk of HIV transmission during childbirth. Prompt initiation of antiretroviral therapy during pregnancy is essential to maximize the chances of preventing vertical transmission.

D. "Antibodies cross the placenta and provide immunity to the newborn."

While it is true that antibodies can cross the placenta and provide passive immunity to the newborn for certain infections, including some viral illnesses, this statement is not directly relevant to preventing HIV transmission from an HIV-positive mother to her newborn. Unlike some infections where maternal antibodies can confer protection to the infant, HIV transmission is not prevented solely by passive immunity. Instead, active measures such as antiretroviral therapy are necessary to reduce transmission risk.

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. B. Encourage her to turn, cough, and deep breathe at frequent intervals. C. Position her right arm below heart level. D. Ask the client how she feels about having her breast removed.

Correct Answer is C

Explanation

A. Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.

- This option is not appropriate because after a right-sided modified-radical mastectomy, it's generally contraindicated to use the affected arm (right arm in this case) for blood pressure measurements, IV lines, or blood draws. This is because such procedures can impede lymphatic drainage and increase the risk of lymphedema. Therefore, the unaffected arm is typically preferred for these purposes to reduce the risk of complications.

B. Encourage her to turn, cough, and deep breathe at frequent intervals.

- While turning, coughing, and deep breathing are essential postoperative nursing interventions to prevent respiratory complications such as pneumonia, they are not specific to the unique needs of a woman who has undergone a mastectomy. These interventions are more focused on general postoperative care rather than addressing the specific concerns related to mastectomy, such as lymphedema management.

C. Position her right arm below heart level.

- This is the correct choice. Positioning the right arm below heart level helps reduce swelling and promotes lymphatic drainage, particularly after surgery involving the lymph nodes, as in a mastectomy. This positioning aids in preventing complications such as lymphedema and supports optimal circulation and fluid balance in the affected arm.

D. Ask the client how she feels about having her breast removed.

- While emotional support and addressing the client's feelings are important aspects of care for a woman who has undergone a mastectomy, this intervention is more appropriate during psychosocial assessment and counseling sessions, rather than immediately postoperatively. At this stage, the focus should be primarily on physical recovery and addressing immediate postoperative needs, such as pain management and prevention of complications like lymphedema. Emotional support can certainly be provided, but it should not be the primary intervention immediately following surgery.

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When performing a clinical breast examination, which would the nurse do first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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