Nokea
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 postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
- A. Cesarean birth
- B. Vaginal birth
- C. Anemia
- D. Multiparity
Correct Answer: A
Rationale: Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors include smoking, obesity, and a history of thromboembolism.
A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?
- A. Assess the infant's bilirubin levels
- B. Initiate phototherapy
- C. Monitor the infant's temperature
- D. Encourage breastfeeding
Correct Answer: A
Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy.
A laboring client's membranes have just ruptured. What is the nurse's next action?
- A. Assess fetal heart rate pattern
- B. Monitor uterine contractions
- C. Administer oxygen
- D. Prepare for delivery
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
A nurse is conducting an infertility assessment for a newly admitted client. Which of the following factors should the nurse identify as affecting the client's fertility?
- A. Premature ovarian failure
- B. Renal calculi
- C. Dysmenorrhea
- D. Recurrent urinary tract infection
Correct Answer: A
Rationale: Premature ovarian failure affects fertility by leading to reduced or absent ovarian function, resulting in decreased estrogen production and irregular menstrual cycles.
A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
- A. Maintain an eye mask over the newborn's eyes
- B. Feed the newborn every hour
- C. Monitor the newborn's temperature
- D. Administer vitamin K
Correct Answer: A
Rationale: Phototherapy is used to reduce bilirubin levels in newborns with jaundice. However, the intense light can cause damage to the newborn's corneas and retinas. The use of an eye mask protects the infant's eyes while allowing the therapy to proceed. Regular monitoring of the newborn's temperature and hydration status is also important, but the eye mask is a key protective measure.