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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?
- A. An irregularly shaped, nontender lump is palpable in the right breast
- B. Tenderness is present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct Answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding because it may indicate breast cancer. The nurse should report this finding to the provider for further investigation.
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A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client¢â‚¬â„¢s membranes have ruptured?
- A. Nonstress test
- B. Biophysical profile
- C. Fern test
- D. Amniocentesis
Correct Answer: C
Rationale: The fern test is used to confirm rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid.
A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5° C (97.7° F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct Answer: B
Rationale: Nasal flaring can indicate respiratory distress and should be reported immediately for further evaluation.
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Aspirin is contraindicated for clients on heparin due to increased bleeding risk.
A nurse is assessing a pregnant client at 32 weeks gestation and notes that the client has gained 5 pounds in one week. Which of the following conditions should the nurse suspect?
- A. Preeclampsia
- B. Gestational diabetes
- C. Anemia
- D. Placenta previa
Correct Answer: A
Rationale: Rapid weight gain, especially in the third trimester, can be a sign of preeclampsia, a condition characterized by hypertension, edema, and proteinuria. This requires immediate medical attention.
A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct Answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery.