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Maternity and Pediatric Nursing 1st (first)

Edition by Ricci, Susan Scott – Test Bank


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Maternity and Pediatric Nursing 1st (first) Edition by Ricci, Susan Scott – Test Bank

Ch. 6: Disorders of the Breast

Page: 183

The nurse is developing the discharge plan for a woman who has had a left-sided radical
1. mastectomy. The nurse is including instructions for ways to minimize lymphedema. Which
suggestion would most likely increase the woman’s symptoms?

A) “Wear gloves when you are doing any gardening.”

B) “Have your blood pressure taken in your right arm.”

C) “Wear clothing with elasticized sleeves.”

D) “Avoid driving to and from work every day.”

Ans: C

Response:
Lymphedema increases when there is obstruction to the lymph flow. Wearing clothing with
elasticized sleeves would compress the extremity, possibly cause trauma, and obstruct the
flow, thus increasing the woman’s risk. Wearing gloves when gardening and using the
unaffected arm for blood pressure readings help to reduce the risk of injury and subsequent
lymphedema. Driving would have no effect on lymphedema.

Page: 183

A laboratory technician arrives to draw blood for a complete blood count (CBC) for a client who
had a right-sided mastectomy 8 hours ago. The client has an intravenous line with fluid infusing
2.
in her left antecubital space. To obtain the blood specimen, the technician places a tourniquet
on the client’s right arm. Which action by the nurse would be most appropriate?

A) Assist in holding the client’s arm still.

B) Suggest a finger stick be done on one of the client’s left fingers.

C) Tell the technician to obtain the blood sample from the client’s left arm.

D) Call the surgeon to perform a femoral puncture.

Ans: B

Response:

The most appropriate action would be to suggest that a finger stick be done. The right arm
cannot be used because the mastectomy was performed on that side. The left arm has an
intravenous infusion, so obtaining blood from this arm would be inappropriate, most likely
leading to inaccurate results. Holding the client’s arm still is inappropriate because neither arm
should be used. Less invasive options should be attempted first before considering a femoral
puncture.

Page: 174

The nurse determines that a woman has implemented prescribed therapy for her fibrocystic
3.
breast disease when the client reports that she has eliminated which from her diet?
A) Caffeine

B) Cigarettes

C) Dairy products

D) Sweets

Ans: A

Response:

Caffeine is a stimulant and eliminating it will help reduce symptoms of fibrocystic breast
disease. Cigarettes, dairy products, and sweets are not associated with symptoms of fibrocystic
breast disease.

Page: 189

When assessing a client with suspected breast cancer, which of the following would the nurse
4.
expect to find?

A) Painful lump

B) Absence of dimpling

C) Regularly shaped mass

D) Nipple retraction

Ans: D

Response:

Malignant breast masses typically are difficult to palpate, painless, irregularly shaped, and
immobile, with nipple retraction and skin dimpling.

Page: 183
A woman who has undergone a right-sided modified-radical mastectomy returns from surgery.
5.
Which nursing intervention would be most appropriate at this time?

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

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

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

D) Position her right arm below heart level.

Ans: C

Response:

Upon return from surgery, the nurse should encourage the client to turn, cough, and deep
breathe at frequent intervals, at least every 2 hours, to help expand collapsed alveoli, clear
inhalation anesthetic agents from the body, and prevent postoperative atelectasis and
pneumonia. Asking the client how she feels about her breast removal should be done at a later
time, when she is more alert and oriented and has had time to think about what has
happened. The sign should state that no BP, IV lines, and lab work should be done on the
client’s right arm. The right arm should be elevated on a pillow to promote lymph drainage.

Page: 187

A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a
6. mastectomy. Which nursing diagnosis would the nurse most likely include in the client’s
preoperative plan of care as being the most important?

A) Risk for deficient fluid volume

B) Activity intolerance

C) Disturbed body image

D) Impaired urinary elimination

Ans: C

Response:

The diagnosis of breast cancer and subsequent removal of the breast via surgery can affect all
aspects of life for the woman, but most significantly her body image due to the loss of a body
part. Therefore, the most important nursing diagnosis would be disturbed body image.
Deficient fluid volume, activity intolerance, and impaired urinary elimination are possible due
to the effects of surgery, but these are not as important as the client’s body image.

Page: 180

A 42-year-old woman is scheduled for a mammogram. Which of the following would the nurse
7.
include when teaching the woman about the procedure?

A) “The room will be darkened throughout the procedure.”

B) “Each breast will be firmly compressed between two plates.”

C) “Make sure to refrain from eating or drinking after midnight.”

D) “A dye will be injected to highlight the breast tissue and its ducts.”

Ans: B

Response:

A mammogram involves taking x-ray pictures of the breasts while they are compressed
between two plastic plates. There is no need to darken the room or to refrain from eating or
drinking after midnight. A ductography involves the injection of dye to highlight the breast
ducts.

Page: 180

During a clinical breast examination, the nurse palpates a well-defined, firm, mobile lump in a
8. 60-year-old woman’s left breast. The nurse notifies the physician. Which of the following
would the nurse anticipate the physician to order next?

A) Mammogram

B) Hormone receptor status

C) Fine-needle aspiration
D) Genetic testing for BRCA

Ans: A

Response:

The characteristics of the palpated mass suggest that it is a benign mass, most likely a
fibroadenoma. However, since other breast lesions have similar characteristics, the lump needs
to be evaluated via mammography. Hormone receptor status is used to determine if a
malignant mass is stimulated to grow by estrogen or progesterone. A fine-needle aspiration
may be done later on if there is reason to suspect a malignancy. Genetic testing for the BRCA
genes would be done to determine a woman’s risk for breast cancer, but this would not be
done next.

Page: 185

A client with advanced breast cancer, who has had both chemotherapy and radiation therapy,
9.
is to start hormonal therapy. Which agent would the nurse expect the client to receive?

A) Progestins

B) Tamoxifen

C) Cortisone

D) Estrogen

Ans: B

Response:

The objective of endocrine therapy is to block or counter the effect of estrogen in the
pathogenesis of cancer. The best-known agent is tamoxifen. Use of progestins along with
estrogens in postmenopausal women increases a woman’s risk for breast cancer. In addition,
estrogen is a considered to play a major role in the development of breast cancer and as such
would not be used. Cortisone is a steroid and would not be used.
Page: 187

As part of discharge planning, the nurse refers a woman to Reach to Recovery. This group’s
10.
primary purpose is to:

A) Help support women who have undergone mastectomies

B) Raise funds to support early breast cancer detection programs

C) Provide all supplies needed after breast surgery for no cost

D) Collect statistics for research for the American Cancer Society

Ans: A

Response:

Reach for Recovery is an organization that gives women and their families opportunities to
express their feelings, verbalize their fears, and get answers. Reach to Recovery volunteers
provide living proof that people can survive breast cancer and lead productive lives. Reach to
Recovery helps raise funds, provide supplies, and collect statistics, but these are not the
program’s primary purpose.

Page: 185

A woman with breast cancer is undergoing chemotherapy. Which of the following side effects
11.
would the nurse interpret as being most serious?

A) Vomiting

B) Hair loss

C) Fatigue

D) Myelosuppression

Ans: D

Response:

Chemotherapy typically causes side effects of nausea, vomiting, hair loss, fatigue, and
myelosuppression. Of these, myelosuppression would be the most serious because it increases
the risk for infection, bleeding, and a reduced red blood cell count, which can lead to anemia.
Page: 187

A woman comes to the clinic reporting a cream-colored nipple discharge with the consistency
of toothpaste. On examination, the area below the areola is red and slightly swollen, with
12.
tortuous tubular swelling. The nurse interprets these findings as suggestive of which of the
following?

A) Fibrocystic breast disorder

B) Intraductal papilloma

C) Duct ectasia

D) Fibroadenoma

Ans: C

Response:

Duct ectasia is manifested by nipple discharge, which can be green, brown, straw-colored, red,
gray, or cream-colored and the consistency of toothpaste. Subareolar redness and swelling can
be noted, along with tortuous tubular swellings beneath the areola. Fibrocystic breast disorder
is characterized by lumpy, tender breasts with possible clear to yellow nipple discharge.
Intraductal papilloma is manifested by a wart-like growth in the mammary ducts near the
nipple that is soft, nontender, mobile, and poorly delineated. A serous, serosanguinous, or
watery discharge from the nipple may occur. Fibroadenoma is characterized by a firm, rubbery,
well-circumscribed, freely mobile mass, usually located in the upper outer quadrant of the
breast.

Page: 188

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

A) Palpate the axillary area.

B) Compress the nipple for a discharge.

C) Palpate the breasts.


D) Inspect the breasts.

Ans: D

Response:

The first step in the clinical breast exam is to inspect the woman’s breasts. The nurse then
palpates the breasts, compresses the nipple to check for a discharge, and finally palpates the
axillary area.

Page: 179

Evaluation of a woman with breast cancer reveals that her mass is approximately 1.25 inches in
14. diameter. Three adjacent lymph nodes are positive. The nurse interprets this as indicating that
the woman has which stage of breast cancer?

A) 0

B) I

C) II

D) III

Ans: C

Response:

Stage II breast cancer is characterized by a tumor from 1 to 2 inches in diameter with spread to
adjacent lymph nodes. Stage 0 cancer is an early stage in which the cancer is extremely
localized. Stage I cancer involves a tumor that is localized and less than 1 inch in diameter.
Stage III cancer involves a tumor that is 2 inches or larger with spread to other lymph nodes
and tissues.

Page: 191
After teaching a woman how to perform breast self-examination, which statement would
15.
indicate that the nurse’s instructions were successful?

A) “I should lie down with my arms at my side when looking at my breasts.”

“I should use the fingerpads of my three middle fingers to apply pressure to my


B)
breast.”

C) “I don’t need to check under my arm on that side if my breast feels fine.”

D) “I need to work from the center of my breast outward toward my shoulder.”

Ans: B

Response:

When performing breast self-examination, the client should use the pads of the middle three
fingers to palpate the breast. When performing the visual part of the procedure, the woman
should look at her breasts with her arms up behind the head, with arms down at the sides, and
while bending forward. When palpating the breast, the woman should check the breasts as
well as the area between the breast and the axilla, the axilla itself, and the area above the
breast up to the clavicle and across the shoulder. When palpating, the woman should start at
the outer edge and work toward the nipple.

Ch. 7: Benign Disorders of the Female Reproductive Tract

Page: 198

A woman is admitted for repair of cystocele and rectocele. She has nine living children. In
1.
taking her health history, which of the following would the nurse expect to find?

A) Sporadic vaginal bleeding accompanied by chronic pelvic pain

B) Heavy leukorrhea with vulvar pruritus

C) Menstrual irregularities and hirsutism on the chin

D) Stress incontinence with feeling of low abdominal pressure

Ans: D

Response:
Cystocele and rectocele are examples of pelvic organ prolapse. Manifestations typically include
stress incontinence and lower abdominal pressure or pain. Complaints of sporadic vaginal
bleeding and chronic pelvic pain are associated with uterine fibroids. Leukorrhea and vulvar
pruritus commonly are associated with an infection. Menstrual irregularities and hirsutism are
associated with polycystic ovarian syndrome.

Page: 199

To assist the woman in regaining control of the urinary sphincter after bladder surgery, the
2.
nurse should teach the client to do which of the following?

A) Perform Kegel exercises daily.

B) Void every hour while awake.

C) Limit her intake of fluid.

D) Take a laxative every night.

Ans: A

Response:

After bladder surgery, the client should perform Kegel exercises daily to strengthen the pelvic
floor muscles. Bladder training with voiding every 3 to 5 hours helps to establish normal
voiding intervals. Fluids should not be limited; however, the woman should avoid fluids that
are irritants, such as caffeinated fluids, soda, and alcohol. Constipation is to be avoided, but a
high-fiber diet rather than daily laxative use is recommended.

Page: 210

When developing the plan of care for a woman who has had an abdominal hysterectomy,
3.
which of the following would be contraindicated?

A) Ambulating the client

B) Massaging the client’s legs


C) Applying elasticized stockings

D) Encouraging range-of-motion exercises

Ans: B

Response:

After an abdominal hysterectomy, massaging the client’s legs would be contraindicated


because the woman is at risk for venous stasis, thrombophlebitis, and thromboembolism.
Ambulation, elasticized stockings, and range-of-motion exercises would be appropriate to
reduce the woman’s risk for thrombophlebitis.

Page: 204

Which of the following would the nurse include when teaching women about preventing pelvic
4.
support disorders?

A) Performing Kegel isometric exercises

B) Consuming low-fiber diets

C) Using hormone replacement

D) Voiding every 2 hours

Ans: A

Response:

Kegel exercises are an effective preventive measure for pelvic support disorders. They may
limit the progression of a mild prolapse and alleviate mild prolapse symptoms. High-fiber
rather than low-fiber diets are appropriate to reduce straining associated with constipation.
Hormone replacement therapy must be highly individualized and is not an appropriate option
for every woman. Normal voiding patterns typically are every 3 to 5 hours. Too frequent or too
infrequent voiding can lead to problems.
Page: 198

5. A client is diagnosed with an enterocele. The nurse interprets this condition as:

A) Protrusion of the posterior bladder wall downward through the anterior vaginal wall

B) Sagging of the rectum with pressure exerted against the posterior vaginal wall

C) Bulging of the small intestine through the posterior vaginal wall

D) Descent of the uterus through the pelvic floor into the vagina

Ans: C

Response:

An enterocele occurs when the small intestine bulges through the posterior vaginal wall,
especially when straining. A cystocele is a protrusion of the posterior bladder wall downward
through the anterior vaginal wall. A rectocele occurs when the rectum sags and pushes against
or into the posterior vaginal wall. Uterine prolapse occurs when the uterus descends through
the pelvic floor and into the vaginal canal.

Page: 201

A woman is scheduled for an anterior and posterior colporrhaphy as treatment for a cystocele.
6. When the nurse is explaining this treatment to the client, which of the following descriptions
would be most appropriate to include?

“This procedure helps to tighten the vaginal wall in the front and back so that your
A)
bladder and urethra are in the proper position.”

“Your uterus will be removed through your vagina, helping to relieve the organ that is
B)
putting the pressure on your bladder.”

“This is a series of exercises that you will learn to do so that you can strengthen your
C)
bladder muscles.”

“These are plastic devices that your physician will insert into your vagina to provide
D)
support to the uterus and keep it in the proper position.”

Ans: A

Response:
An anterior and posterior colporrhaphy tightens the anterior and posterior vaginal wall, and
the supportive tissue between the vagina and bladder is folded and sutured to bring the
bladder and urethra into proper position. Removal of the uterus through the vagina refers to a
vaginal hysterectomy. Exercises to strengthen the bladder muscles are called Kegel exercises.
Plastic devices inserted to provide support are called pessaries.

Page: 208

7. The nurse would be least likely to find which of the following in a client with uterine fibroids?

A) Irregularly shaped, enlarged uterus

B) Acute pelvic pain

C) Menorrhagia

D) Complaints of bloating

Ans: B

Response:

Typically the woman with uterine fibroids complains of chronic pelvic pain, with menorrhagia
and bloating. Palpation reveals an enlarged, irregularly shaped uterus.

Page: 213

A client with polycystic ovarian syndrome (PCOS) is receiving oral contraceptives as part of her
8.
treatment plan. The rationale for this therapy is to:

A) Restore menstrual regularity

B) Induce ovulation

C) Improve insulin uptake

D) Alleviate hirsutism
Ans: A

Response:

Oral contraceptives are used as treatment for PCOS to restore menstrual irregularities and
treat acne. Ovulation induction agents such as Clomid are used to induce ovulation.
Glucophage is used to improve insulin uptake. Mechanical hair removal methods are used to
treat hirsutism.

Page: 199

When teaching a woman how to perform Kegel exercises, the nurse explains that these
9.
exercises are designed to strengthen which muscles?

A) Gluteus

B) Lower abdominal

C) Pelvic floor

D) Diaphragmatic

Ans: C

Response:

Kegel exercises strengthen the pelvic floor muscles to support the inner organs and prevent
further prolapse. They have no effect on the gluteal, lower abdominal, or diaphragmatic
muscles.

Page: 204

A postmenopausal woman with uterine prolapse is being fitted with a pessary. The nurse
10.
would be most alert for which side effect?

A) Increased vaginal discharge

B) Urinary tract infection


C) Vaginitis

D) Vaginal ulceration

Ans: D

Response:

Use of a pessary can lead to pressure necrosis. Postmenopausal women with thin vaginal
mucosa are highly susceptible to vaginal ulceration. Increased vaginal discharge, urinary tract
infections, and vaginitis are possible side effects that could be seen in any woman fitted with a
pessary.

Page: 204

When preparing the discharge teaching plan for the woman who had surgery to correct pelvic
11.
organ prolapse, which of the following would the nurse include?

A) Care of the indwelling catheter at home

B) Emphasis on coughing to prevent complications

C) Return to usual activity level in a few days

D) Daily douching with dilute vinegar solution

Ans: A

Response:

Following surgery to repair a pelvic organ prolapse, the nurse would teach the woman about
caring for the indwelling catheter, which will remain in place for approximately 1 week.
Activities that increase intra-abdominal pressure, such as straining, sneezing, or coughing,
should be avoided. The woman also should avoid heavy lifting or straining for several weeks.
Pelvic rest is prescribed until the operative area is healed in 6 weeks. Douching is indicated if
the woman had a pessary inserted, not surgery.
Page: 214

A woman with polycystic ovary syndrome tells the nurse, “I hate this disease. Just look at me! I
have no hair on the front of my head but I’ve got hair on my chin and upper lip. I don’t feel like
12.
a woman anymore.” Further assessment reveals breast atrophy and increased muscle mass.
Which nursing diagnosis would most likely be a priority?

A) Situational low self-esteem related to masculinization effects of the disease

B) Social isolation related to feelings about appearance

C) Risk for suicide related to effects of condition and fluctuating hormone levels

D) Ineffective peripheral tissue perfusion related to effects of disease on vasculature

Ans: A

Response:

The woman is verbalizing how she sees herself in light of the manifestations of PCOS. She is
exhibiting a negative self-image. Therefore, the nursing diagnosis of situational low self-esteem
would be a priority. There is no information about the woman’s participation in social
activities. Her statements do not reflect that she might hurt herself. PCOS is associated with
long-term health problems, but this is not evidenced by the scenario.

Page: 205

After teaching a local woman’s group about incontinence, the nurse determines that the
13. teaching was successful when the group identifies which of the following as characteristic of
stress incontinence?

A) Feeling a strong need to void

B) Passing a large amount of urine

C) Most common in women after childbirth

D) Sneezing may be an initiating stimulus

Ans: D

Response:
Stress incontinence is characterized by the involuntary passage of a small amount of urine in
response to an increase in intra-abdominal pressure, such as with sneezing, coughing, laughing,
or physical exertion. It is most common in women in their 40s and 50s due to the weakening of
the muscles and the ligaments in the pelvis after childbirth.

Page: 198

A woman is being evaluated for pelvic organ prolapse. A postvoid residual urine specimen is
14. obtained via a catheter. Which residual volume finding would lead the nurse to suspect the
need for further testing?

A) 50 mL

B) 75 mL

C) 100 mL

D) 120 mL

Ans: D

Response:

A postvoid residual urine specimen of greater than 100 mL indicates the need for further
urodynamic evaluation and testing.

Page: 200

After teaching a woman with pelvic organ prolapse about dietary and lifestyle measures, which
15.
of the following statements would indicate the need for additional teaching?

A) “If I wear a girdle, it will help support the muscles in the area.”

B) “I should take up jogging to make sure I exercise enough.”

C) “I will try to drink at least 64 oz of fluid each day.”

D) “I need to increase the amount of fiber I eat every day.”


Ans: B

Response:

High-impact aerobics, jogging, or jumping repeatedly should be avoided to reduce the risk of
increasing intra-abdominal pressure. Wearing a girdle or abdominal support helps to support
the muscles surrounding the pelvic organs. The woman should consume at least eight 8-oz
glasses of fluid daily and replace refined low-fiber foods with high-fiber foods.